Cardiology

A 67-year-old woman with insulin-dependent diabetesmellitus and uncontrolled hyperglycemia complained offatigue and malaise. For 2 years, a draining ulcer hadbeen present on the bottom of her left foot.

High-grade fever, chills, fatigue, malaise, and anorexia developed in a 35-year-old man following subclavian catheterization because of chronic renal failure of unknown cause. The patient, who had long-standing diabetes mellitus, was admitted to the ICU with the diagnosis of possible sepsis. The next day, he was found to have a grade 2/6 systolic murmur compatible with tricuspid regurgitation. This was confirmed when a 4-chamber echocardiogram (A) revealed a large single piece of vegetation (2 arrows) lying on the tricuspid valve, flapping in and out of the right ventricle. In a 2-dimensional echocardiogram of the right atrium and right ventricle (B), 3 arrows point to the vegetation. (RV, right ventricle; LV, left ventricle; RA, right atrium; LA, left atrium; TV, tricuspid valve.)

An 83-year-old woman is brought by her daughter for evaluation becauseof increasing confusion during the past few days. The patienthas early Alzheimer dementia, hypertension, and type 2 diabetes. She takes donepezil, 10 mg/d;lisinopril, 5 mg/d; and glipizide, 5 mg bid. She is unable to bathe and dress herself as well as previously,has been crying for no apparent reason, and has lost her appetite.

A 20-year-old woman presents with a 3-week history of a pruritic, progressivelyenlarging erythematous lesion on one arm. She has a cat and recentlystarted horseback riding lessons. She is otherwise healthy and takes nomedication.

Despite the manydouble-blind,placebo-controlledtrials thathave demonstratedthe efficacy of statins inreducing the risk of cardiovascularevents, a largenumber of patients who aretreated with these drugsstill experience suchevents. This may be becausepatients who requireintensive lipid lowering arenot receiving adequatedosages of statins.

Two weeks earlier, this 66-year-old man had been hospitalized because of leftsided chest pain. However, cardiac evaluation revealed no abnormalities.

A 53-year-old man with type 2 diabetes mellitus and hypertension presented to the emergency department with pain in his left upper chest and back, neck, and shoulder. The pain increased with passive and active range of motion testing and decreased at rest. His physical examination was unremarkable except for restricted left shoulder movement and generalized tenderness in the left shoulder area.

A 30-year-old man presentedwith severe left flankpain radiating to his abdomenand gross hematuriaof 5 to 10 days’ duration.He also reported a 4- to 6-monthhistory of nausea with intermittentvomiting, anorexia, and progressiveweight loss. He took no medicationsand had no allergies.

A mildly painful, nonpruritic rash on the forearms and legs prompted a 42-year-old man to go to the emergency department. The patient noted the rashwhen he awoke that morning. He had had joint pain and fever for the past7 days and generalized malaise with chills that began about 3 days earlier.He had no significant medical history.

Hypertensive crises encompass a spectrum of clinical situations thathave in common elevated blood pressure (BP) and progressive or impendingtarget organ damage. Each year more than 500,000 Americans (about1% of all persons with hypertension in the United States) have a hypertensivecrisis. In large urban areas, 25% of visits to the medical section of any givenemergency department (ED) are attributable to a hypertensive crisis.

A 35-year-old woman (gravida 3, para 2) presented at 25 weeks’ gestation with a 24-hour history of continuous, pressure-like, retrosternal chest pain, radiating only to the back. The pain worsened when she lay down, took deep inspirations, or coughed; it diminished when she leaned forward. The patient had no significant medical history and was not taking any medications; she denied fever and illicit drug use.

An obese 61-year-old man who hadchronic obstructive pulmonary diseaseand sleep apnea heard a “pop”in his stomach while lifting a heavyweight; severe abdominal pain followed.He was short of breath thenext morning, and his physician empiricallyprescribed cephalexin.

A 70-year-old man with a history of peptic ulcer disease presented with a 1-dayhistory of epigastric pain. Abdominal examination revealed mild epigastrictenderness. A pneumoperitoneum was discovered on a chest film (A), and aleft decubitus chest film (B) confirmed this diagnosis.

A 70-year-old woman with no previousmedical problems had had progressivedyspnea and generalized weaknessfor the past several days. She washypotensive (73/31 mm Hg), tachycardic(120 beats per minute), andtachypneic (28 breaths per minute);oxygen saturation (room air) via pulseoximetry was 84%.

Over the previous 6 months, a59-year-old man had experienced lethargy,fatigue, poor appetite, cold intolerance,and abdominal distention. Hisvital signs were normal; physical examinationrevealed periorbital andpretibial edema, distant heart sounds,and delayed reflexes.

A 72-year-old man with a history of rheumatic heart disease presented with pulmonary congestion and syncope. Results of the cardiac examination suggested mitral stenosis and atrial fibrillation with a controlled ventricular response.

A 52-year-old man complains of nausea, fever, and malaise following a 2-day diarrhealillness that developed at the end of a family vacation in New England.Two family members suffered a similar illness, characterized by watery diarrhea.Symptoms developed in all who were affected within 24 hours of eatinghamburgers at a local restaurant.

A 70-year-old man who had just completeda course of trimethoprim-sulfamethoxazolefor a urinary tract infectionpresented with palpable purpuraand cutaneous erosions of acute onseton his legs (A). He also had massivescrotal edema and purpura (B).

Painful blue toes developed in a 72-year-old woman with coronary artery andperipheral vascular disease after she underwent angiography.

A 16-year-old girl was bothered byankle pain and “red spots” on herlower legs. These symptoms clearedin a few days without treatment. Sixweeks later, after returning from anall-day outing at a fair, she noticedthat the spots had reappeared (A)and hemorrhagic lesions had developedon the right ankle (B) and leftheel (C). After removing her shoes,the teenager felt severe pain in bothankles, particularly the right.

A 57-year-old man with a history of venous stasis leg ulcerationwondered about the “white spots” on his leg. Thecondition is atrophie blanche, which manifests as smooth,ivory-white macules and plaques of sclerosis stippled withtelangiectasia that often are surrounded by mild to moderatepigmentation.

Redness, irritation, and diplopia developedover 2 to 3 weeks in a 55-yearoldman’s left eye (A). The injectionworsened and was unresponsive toeye drops. Ptosis, mild proptosis, andelevated intraocular pressure developed.A bruit was auscultated overthe affected eye.

Sudden pain and a pulsatile swellingof the right upper medial thigh concernedan 80-year-old woman (A).Coronary angioplasty had been performedthrough this site 5 weeksearlier.

Four months after a patchy, macular,erythematous spot erupted on thedorsum of a 63-year-old woman’s leftfoot, the area became ulcerated,tender, and painful. The 1.2-cm ulcerwas covered by a hemorrhagic crustsurrounded by a cyanotic reticulardiscoloration of the skin.

A 65-year-old woman, who was confined to a wheelchairbecause of severe rheumatoid arthritis, was concernedabout nodules that had erupted on her fingers and handsduring the previous 3 weeks (A). Her medical historyincluded colon cancer, chronic renal insufficiency, anemia,and hypertension. The nonpruritic nodules were painfulwhen they began to form under the skin; however, oncethey erupted, the pain disappeared.