A 54-Year-Old Man Comes to the Emergency Department After an Episode

question 287

Multiple Choice

A 54-year-old man comes to the emergency department after an episode of syncope.  While he was watching television 30 minutes ago, he experienced sudden-onset chest pressure followed by a syncopal episode.  He regained consciousness within a minute but continues to have chest "heaviness" and shortness of breath.  Two days ago, the patient returned home from an extended car trip.  He has a history of hypertension, osteoarthritis, and prostate cancer treated with brachytherapy.  He is a former smoker with a 15-pack-year history and does not use alcohol or illicit drugs.  Temperature is 38.3 C (100.9 F) , blood pressure is 81/50 mm Hg, pulse is 110/min and regular, respirations are 26/min, and pulse oximetry is 92% on room air.  The lungs are clear to auscultation.  Cardiac examination shows a nondisplaced point of maximal impulse, with no murmurs but an accentuated pulmonic component of S2.  Laboratory results are as follows:
ECG shows sinus tachycardia with nonspecific ST-segment and T-wave changes.  CT angiography reveals filling defects in the bilateral main pulmonary arteries.  Blood pressure after multiple fluid boluses is 85/60 mm Hg and pulse is 108/min.
Which of the following findings in this patient is most predictive of increased 30-day mortality?

• A)Fever
• B)Hypotension
• C)Hypoxemia
• D)Loud pulmonic component of S2
• E)Respiratory alkalosis

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