Chief Complaint: 68-year-old man who collapsed while mowing lawn
History: Roger Crocket, a 68-year-old man with a 40-pack-year smoking history and recent complaints of angina upon exercising, collapsed while mowing his lawn. Paramedics arriving at the scene found him unconscious, not breathing, and without a pulse. CPR was successfully performed and Roger was transported to the hospital. An ECG was suggestive of an anterior wall myocardial infarction, and he was given an intravenous solution of tissue plasminogen activator (TPA). Elevated blood creatine phosphokinase (CPK) levels measured over the next 2 days confirmed the diagnosis. Coronary angiography was performed a week later, revealing the following results:
Circumflex artery: 20% blocked
Right coronary artery 15% blocked
Left anterior descending artery (LAD): 95% blocked
1) While listening to his heart with a stethoscope, you notice a high pitched, blowing, systolic murmur, heard best directly under the left nipple. A review of Rogers medical records shows no prior history of a heart murmur. What is causing this new murmur?
2) Is the cause of the murmur in any way related to his heart attack? Explain.
3) While listening to his breathing with a stethoscope, you hear some wheezing and rales ('crackling noises'). Explain these findings.
4) A chest X-ray taken two weeks after his collapse shows a markedly enlarged cardiac silhouette and generalized haziness at the bases of the lungs.
A. Why is the heart enlarged?
B. Whay are the lungs "hazy" on chest X-ray?