A 12-year-old girl is brought to your primary care center by her parents for having fever, joint pains and a rash. The pain moves from joint to joint. Her parents are particularly concerned about involuntary, uncoordinated movements of her tongue, face and upper extremities. On review of systems, you discover that he suffered from a sickness 2 to 3 weeks ago, which was assumed to be a viral infection and treated with acetaminophen and fluids. Physical examination is notable for involuntary movements in the face and upper extremities. When you asked the patient to squeeze your hand, she made repetitive irregular squeezes. There are subcutaneous nodules on both upper and lower extremities. You also noticed branching erythematous ring-shaped rash over the extremities. Which of the following most likely preceded this patient’s current condition?

A 72-year-old man presents to your clinic with a 4-month history of worsening shortness of breath. His exercise tolerance decreased, he has been having chest pains and lightheadedness. He also changed his shoes because of swelling in both feet. He finds that he becomes short of breath after working a couple of hours in an 8 hour work day. He awakens at night, gasping for breath. He has to prepare himself with pillows in order to sleep. His temperature is 99 ⁰ F, heart rate is 62 beats per minute, respiratory rate is 17 breaths per minute, and blood pressure is 190/75 mm Hg. On physical examination, his apical impulse is displaced to the left and downard. There are rales over both lower lung fields. On cardiac auscultation, there are three distinct murmurs: a high-pitched, early diastolic murmur loudest at the left lower sternal border, a diastolic rumble heard at the apex, and a crescendo–decrescendo systolic murmur heard at the left upper sternal border. Chest x-ray film shows cardiomegaly and pulmonary edema. Of the following, which is the most likely diagnosis in this patient?

An 82-year-old man comes to the emergency room complaining of chest pains with walking, shortness of breath with activity and lightheadedness. A week ago he also passed out in the living room. He has had these symptoms for many months but they became worse in the last 2 weeks to the point, in his words, ‘I can’t take it any more’. Physical examination is significant for a systolic crescendo-decrescendo murmur, a palpable LV heave, a weak aortic second sound, and reversed splitting of the second sound. You also notice mild pitting edema in both lower extremities. Echocardiogram revealed an aortic valve area of less than 1.0 cm2 and evidence of an immobile aortic valve. During your discussions with the patient about treatment options, he informed you that he would like to have a treatment that would prolong his life because he would like to attend his granddaughter’s wedding next year. If complications arise due to the surgery, he would not mind a permanent pacemaker or repeat interventions to deal with the complications of the surgery. He also would like to have a shorter hospital stay after the surgery because, ‘I am not a hospital guy’. Which of the following treatments is favored in this patient?

A 68-year-old man presents to the clinic complaining of worsening exertional dyspnea. He feels short of breath even after walking with his dog more than a couple of blocks from his home. He has a persistent cough that produces blood-tinged mucus. He does not have chest pain at rest but has experienced retrosternal chest pressure with strenuous exertion. He admits that he passed out a week ago for unclear reasons. He wakes up at night feeling short of breath. His medical history is significant for gout, angina and an episode of endocarditis ten years ago. On physical examination, he is afebrile, with a heart rate of 88 beats per minute (bpm), blood pressure of 140/95 mm Hg, and respiratory rate of 18 breaths per minute. Examination of the head and neck reveals distended neck veins. On cardiac examination, you detect a soft S2 and a coarse, late-peaking crescendo-decrescendo, systolic ejection murmur heard best at the aortic area of the heart. On lung auscultation, you heard bibasilar posterior crackles. He has swelling in his ankles, lower legs and abdomen. He gained over 10 pounds in the last two weeks. Which of the following indicates the worst prognosis for this patient?

A 68-year-old man presents to the clinic complaining of worsening exertional dyspnea. He feels short of breath even after walking with his dog more than a couple of blocks from his home. He does not have chest pain at rest but has experienced retrosternal chest pressure with strenuous exertion. He admits that he passed out a week ago for unclear reasons. He wakes up at night feeling short of breath. He denies any significant medical history. He has not seen a doctor in 25 years. On physical examination, he is afebrile, with a heart rate of 88 beats per minute (bpm), blood pressure of 140/95 mm Hg, and respiratory rate of 18 breaths per minute. Examination of the head and neck reveals distended neck veins. On cardiac examination, you detect a soft S2 and a coarse, late-peaking crescendo-decrescendo, systolic ejection murmur heard best at the aortic area of the heart. You suspected a cardiac disorder in this patient. Which of the following is the best initial diagnostic modality to confirm the diagnosis?

A 64-year-old woman presents to the emergency room complaining of shortness of breath, fatigue, palpitations and chest pain. She is not able to lie down on her bed because it makes her shortness of breath worse. On physical examination, you note that she has a holosystolic, high-pitched, blowing murmur with a midsystolic click heard best at the apex with radiation to the axilla. When you used some bedside maneuvers, the murmur decreased in intensity with Valsalva and standing and increased in intensity with handgrip. Which of the following is the most likely diagnosis in this patient?

A 24-year-old man presents to the emergency room with acute chest pain and a nonproductive cough for the last 3 days. The chest pain increases with inspiration, ‘it is always there’, it is ‘bearable’ and sometimes moves to his neck and back. In review of systems, he reports that the chest pain gets worse with lying flat and improves by sitting up. His medical history is significant for Covid-19 infection ten days ago. He attends a local university and is a member of the athletic team. His temperature is 101 ⁰ F, heart rate is 62 beats per minute, respiratory rate is 12 breaths per minute, and blood pressure is 110/80 mm Hg. Physical examination is significant for a friction rub. No lymphadenopathy, no skin rashes, no oral abnormalities noted. ECG reveals diffuse upsloping ST segment elevation and PR segment elevation in lead aVR and PR segment depression in other leads.No pathologic Q waves or reciprocal changes are present .Laboratory tests reveal elevated troponin and C reactive protein. Chest x-ray is normal. Echocardiogram is normal. Which of the following is the most likely diagnosis in this patient?