Red flags in chest painDownloads

A 36-year-old man presents to the physician with difficulty in breathing for 3 hours. There is no history of chest pain, cough or palpitation. He is a chronic smoker and underwent elective cholecystectomy one month back. There is no history of chronic or recurrent cough, wheezing or breathlessness. His temperature is 38.2°C (100.8°F), pulse is 108/min, blood pressure is 124/80 mm Hg, and respirations are 25/min. His arterial oxygen saturation is 98% in room air as shown by pulse oximetry. After a detailed physical examination, the physician orders a plasma D-dimer level, which was elevated. A contrast-enhanced computed tomography (CT) of the chest shows a filling defect in a segmental pulmonary artery on the left side. Which of the following signs is most likely to have been observed by the physician during the physical examination of this patient’s chest?

A 74-year-old woman is brought by ambulance to the emergency department and presents with a complaint of excruciating chest pain that started about 45 minutes ago. The patient was sitting in the garden when she 1st noticed the pain in the upper abdomen. The pain has persisted and now localizes underneath of the sternum and the left shoulder. Milk of magnesia and aspirin were tried with no relief. The patient had previous episodes of chest pain that were of lesser intensity and rarely lasted more than 10 minutes. She is diabetic and has been managed for hypertension and rheumatoid arthritis in the past. On examination, the patient is breathless and sweating profusely. The vital signs include blood pressure 140/90 mm Hg and heart rate 118/min. The electrocardiogram (ECG) shows Q waves in leads V2 and V3 and raised ST segments in leads V2, V3, V4, and V5. Laboratory studies (including cardiac enzymes at 6 hours after admission show: Hematocrit 45% Troponin T 1.5 ng/mL Troponin I 0.28 ng/mL Creatine kinase (CK)-MB 0.25 ng/mL The patient is admitted and started on analgesia and reperfusion therapy. She shows initial signs of recovery until the 6th day of hospitalization when she starts vomiting and complaining of dizziness. Physical examination findings at this time included heart rate 110/min, temperature 37.7°C (99.9°F), blood pressure 90/60 mm Hg. Jugular venous pressure is 8 cm. A harsh pansystolic murmur is present at the left lower sternal border. ECG shows sinus tachycardia and ST-segment elevation with terminal negative T waves. Laboratory studies show: Hematocrit 38% Troponin T 1.15ng/mL Troponin I 0.18 ng/mL CK-MB 0.10 ng/mL Which of the following best explains the patient's current clinical condition?