A 49 year old white male with a history of ethanol abuse,
bronchial asthma and hypertension presents to the ED
with a six hour complaint of severe chest pain. He became
markedly dyspnic two hours prior to his presentation.
Physical exam reveals that the
patient is in marked respiratory distress and complains
of lower anterior and posterior chest pain. BP 110/70
mm Hg in the right arm. Pulse is 110/min and regular.
Respirations labored at 35/min. He is afebrile. Neck
veins are flat at 30 degrees and there is no HJR.
S1 is muffled. There is a grade 2/6 systolic ejection
murmur at the LUSB together with a very brief grade
2/6 early diastolic decrescendo murmur. An S4 gallop
is present at the apex together with a soft, intermittent
S3. The lungs are relatively clear, except for occasional
scattered rhonchi. The abdomen is unremarkable and there
is no pitting edema of the legs.
ONE of the following is the most likely diagnosis?