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A 65-Year-Old Man Comes to the Emergency Department Due to Sudden-Onset

question 559

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A 65-year-old man comes to the emergency department due to sudden-onset chest pain followed by syncope. The pain started an hour ago, during which he had an episode of syncope lasting 1-2 minutes. The patient has had no dyspnea or palpitations. He has never had similar symptoms before. Medical history is significant for hypertension and a 40-pack-year smoking history. Blood pressure is 190/110 mm Hg in both arms; pulse is 100/min and regular; and respirations are 24/min. Pulses are symmetric and equal in all extremities. Jugular venous pressure is normal. Breath sounds are normal on both sides. There is an S4 gallop. ECG shows changes consistent with left ventricular hypertrophy. Serum troponin is normal. D-dimer is elevated. Chest x-ray shows an enlarged cardiac silhouette but is otherwise unremarkable. CT scan of the chest is obtained and is shown below: $A 65-year-old man comes to the emergency department due to sudden-onset chest pain followed by syncope. The pain started an hour ago, during which he had an episode of syncope lasting 1-2 minutes. The patient has had no dyspnea or palpitations. He has never had similar symptoms before. Medical history is significant for hypertension and a 40-pack-year smoking history. Blood pressure is 190/110 mm Hg in both arms; pulse is 100/min and regular; and respirations are 24/min. Pulses are symmetric and equal in all extremities. Jugular venous pressure is normal. Breath sounds are normal on both sides. There is an S4 gallop. ECG shows changes consistent with left ventricular hypertrophy. Serum troponin is normal. D-dimer is elevated. Chest x-ray shows an enlarged cardiac silhouette but is otherwise unremarkable. CT scan of the chest is obtained and is shown below: Which of the following is the best next step in management of this patient? A) Administration of thrombolytic therapy B) Admission to critical care unit for close blood pressure control C) Emergent surgical repair D) Unfractionated heparin infusion with close PTT monitoring E) Urgent coronary angiogram$ Which of the following is the best next step in management of this patient?

Definitions:

Appearance-Reality Distinction

The cognitive skill to differentiate between how things appear and how they actually are, which develops in early childhood.

Metacognition

The awareness and understanding one has of their own thought processes, often used to improve learning and problem-solving skills.

Animism

The belief that inanimate objects are alive and have feelings and intentions; a characteristic of preoperational reasoning.

Lateralized

Pertains to the specialization of function in one hemisphere of the brain or the other.