Approach to shock Quiz: Ace Your Exams

A 35-year-old man presents to the emergency department due to shortness of breath and lethargy. He also has sharp anterior chest pain. The patient was seen yesterday at an urgent care clinic and was prescribed azithromycin for a suspected upper respiratory infection. Past medical history is notable for mild intermittent asthma treated with an as needed albuterol inhaler. Temperature is 37.7ºC (99.9ºF), pulse is 112/min, blood pressure is 79/54 mmHg, respirations are 20/min, and SpO₂ is 90% on room air. On physical examination, the patient is lethargic. The skin is cool to touch and pale, and capillary refill is delayed. On lung auscultation, there are bibasilar crackles and decreased breath sounds at both lung bases. Pressing on the right upper quadrant of the abdomen causes a prolonged elevation of the jugular venous pulse. Moderate non-pitting edema is present bilaterally up to the proximal tibias. Which of the following is the most likely cause of this patient’s presentation?