The case below is followed by a choice of diagnoses. Select the answer choice that best describes this patient’s condition.
An independent 90-year-old retired teacher with diet controlled diabetes, hypertension, and hyperlipidemia was in her usual state of health until three days prior to presentation when she developed substernal, nonradiating chest pressure at rest associated with mild nausea, malaise, and fatigue. She took an antacid for presumed dyspepsia and delayed seeking medical care until she was no longer able to ambulate around her home due to dyspnea on even minimal exertion. On presentation to the emergency department her blood pressure is 90/60, heart rate 80 bpm, respiratory rate 18/min, and oxygen saturation 100% on 2L nasal cannula. On exam, her jugular vein is distended with pulsations noted 10 cm above the right atrium. She appears comfortable and is able to answer questions in complete sentences. Cardiac auscultation reveals a regular, normal s1/s2 with a harsh, high-pitched 3 out of 6 holosystolic murmur best heard at the left lower sternal border. The murmur radiates throughout the precordium but not to the axilla. Pulmonary examination is noteworthy for good air movement bilaterally but faint crackles are detected at both lung bases. Lower extremities are warm and well perfused with 1+ pitting edema. Laboratory exam reveals elevated cardiac biomarkers: Troponin T 3.09 (normal <0.01 ng/mL), CKMB 10.6 (normal <5 ng/ml). ProBNP is also markedly elevated at 43,000 (normal <300 pg/ml). Her EKG shows sinus rhythm with new right bundle branch block, ST elevations in lead V1-V3 and pathologic q-waves in these same leads. Chest X-ray shows mild vascular congestion and small bilateral pleural effusions.
Which of the following diagnoses is most likely?
A. Acute myocardial infarction complicated by ventricular septal defect
B. Senile aortic stenosis
C. Acute myocardial infarction complicated by papillary muscle rupture
D. Left ventricular free wall rupture due to myocardial infarction
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