Cardiology

A 60-year-old comatose man was brought to the emergency department (ED). He had a history of diabetes, hypertension, and alcohol abuse. Relatives reported that the patient was noncompliant with his antihypertensive medication regimen.

A 46-year-old woman sought treatment of vaginal pruritus of 6 months' duration. She also was bothered by generalized skeletal aching that was most prominent in her legs. The patient had a history of hypertension.

A 16-year-old girl was bothered by ankle pain and “red spots” on her lower legs. These symptoms cleared in a few days without treatment. Six weeks later, after returning from an all-day outing at a fair, she noticed that the spots reappeared and hemorrhagic lesions developed on the right ankle and left heel. After removing her shoes, the teen-ager felt severe pain in both ankles, particularly the right.

Livedo reticularis is the cutaneous manifestation most frequently associated with the antiphospholipid syndrome (APS). It manifests as a dusky, violaceous vascular discoloration with a reticulated pattern on the upper and lower extremities.

A 47-year-old woman presented to the emergency department with chest pain of sudden onset. The patient had no history of coronary artery disease, peptic ulcer, gastroesophageal reflux disease, or similar episodes of chest pain. She had not traveled long distances or suffered trauma or injury recently.

Cirrhosis and ascites developed in a 52-year-old man with a history of chronic hepatitis C and ethanol abuse. He was hospitalized because of bleeding esophageal varices, which were successfully treated with elastic band ligation.

Intermittent dysphagia had bothered a 75-year-old woman for 6 months. She said that she felt an obstruction in her lower chest. Recent weight loss was attributed to the inability to swallow.

These collections of dilated vessels deep in the dermis and subcutaneous tissue are present at birth. They usually present as bluish or reddish lesions that are cystic, firm, and compressible. About 60% to 80% of cavernous hemangiomas undergo spontaneous involution, often with central clearing and fibrosis.

The initial complaint of a 79-year-old woman was of mild headache, neck pain, and sore throat. She had a history of hypertension, diabetes mellitus, and heavy cigarette smoking. Examination by an otolaryngologist, which included laryngoscopy, revealed no abnormalities. Three weeks later, the patient's throat and neck pain became more severe. She had no arthralgias, visual loss, fever, or worsening head pain.

During a routine physical examination of a healthy 7-year-old African-American boy, this striking-and puzzling-hyperpigmentation was noted on his palms.

A 50-year-old man with a history of diabetes, hypertension, seizure disorder, and alcohol abuse sought treatment for a rash and painful ulcerations of the hand, face, and scalp, which had bothered him for 1 month. The patient also complained of pruritus.

An 18-month-old girl was noted to have somatic overgrowth, macroglossia, macrostomia, fading telangiectatic nevi over the glabella and eyelids, vertical creases on the earlobes, a short nose with anteverted nares, and a long philtrum. She also had an ejection systolic murmur best heard at the left mid- and upper sternal border, compatible with an atrial septal defect.

Ten days after ballet practice, a 9-year-old girl noticed a nonpruritic, petechial rash on her lower legs. Swelling of the ankles and knees was also apparent. The patient was afebrile, otherwise healthy, and had no abdominal pain. There was no family history of blood dyscrasias. The patient was taking no medications.

A 73-year-old man who had a history of long-standing essential hypertension, congestive heart failure, mild renal insufficiency, atrial fibrillation, and a mitral valve replacement presented with refractory hypertension. His medications included labetalol, irbesartan, and furosemide.

A 74-year-old man was evaluated for iron deficiency anemia. The gastrointestinal (GI) work-up showed Schatzki's ring, gastritis, and two adenomatous polyps. Oral iron therapy was initiated, and the anemia improved.

A 64-year-old asymptomatic woman with a 10-year-history of hypertension was referred for blood pressure control. She had no other significant medical history. The patient denied exertional chest discomfort or dyspnea. Her medications included atenolol, lisinopril, and hormone replacement therapy.

A 52-year-old woman who was undergoing chemotherapy for lymphoma was admitted to the hospital with fever of a few days' duration. The patient had smoked cigarettes for many years; she had no history of deep venous thrombosis.

A 21-year-old man slept in a car in upstate New York for three winter nights. Discomfort and swelling of his toes developed, which progressed to marked discoloration of the digits.

A 47-year-old woman complained of pain and swelling of the right knee of 3 days' duration. Positive fullness of the popliteal area with no pulsations was discerned. Doppler ultrasound showed a 2.5 cm × 1.5 cm cystic structure in the right popliteal region; this confirmed the diagnosis of a Baker's cyst.

A 49-year-old woman noticed a growing lesion near the inner corner of her left upper eyelid. The lesion had become conspicuous because of its size and color; the patient wanted it removed.

A 56-year-old man who had hematuria for 2 weeks underwent ultrasonography. This disclosed a well-circumscribed cyst in the lower pole of the left kidney and echogenic foci in the upper pole of the right kidney, without any evidence of posterior shadowing. A hyperechoic, well-circumscribed, circular focus was also seen in the right lobe of the liver. Abdominal CT confirmed the presence of a left renal cyst and revealed a 4.7-cm hypodense lesion in the right lobe of the liver, which suggested hemangioma.

Four months after coronary artery bypass surgery, a 77-year-old man began to suffer severe pain in his feet. Multiple necrotic areas developed on the toes.

Erythema elevatum diutinum (EED) is a rare and usually chronic form of vasculitis. It has been postulated that EED is the result of immune complex formation in small vessels secondary to some antigenic stimulation.

An 8-year-old boy was brought to his pediatrician for well-child care. On physical examination, an irregularly irregular heart rate was detected.

For 2 years, a 60-year-old woman with long-standing hypertension had experienced worsening dizzy spells, fatigue, and chest discomfort. She also had cold extremities, significant dyspnea on exertion, and orthopnea. The patient was taking amlodipine and furosemide.

For the past year, a 45-year-old man experienced dull, aching chest pain and breathlessness following routine work. He had no history of fever, cough, dysphagia, or change in voice.

While working in her garden in Virginia, a 40-year-old woman felt a sudden, sharp pain between the fingers of her right h and saw blood coming from an open wound. Immediately, she experienced a burning sensation at the site and noticed numbness and swelling in the hand. The patient was rushed to the emergency department.

Dyspnea, orthopnea, and weight loss sent a 40-year-old woman for medical consultation. Fifteen years earlier, the patient had been nephrectomized because of left kidney lithiasis. There was no history of other symptoms or diseases.

A mother, fearing that her 4-year-old son had been abused at his day-care center, rushed him to the emergency department, where an evaluation revealed a platelet count of 1,000/µL. Except for bruises on the boy's face and legs, the physical findings were normal. Bone marrow aspiration showed numerous megakaryocytes and was otherwise normal. The youngster's history included treatment for bronchitis, sinusitis, and conjunctivitis 2 weeks earlier.

A mildly painful, nonpruritic rash on the forearms and legs prompted a 42-year-old man to go to the emergency department (ED). The patient noted the rash when he awoke that morning. He had had joint pain and fever for the past 7 days and generalized malaise with chills that began about 3 days earlier. He had no significant medical history.