Michael D. Smith, MD

THE CASE: A 77-year-old woman who has had shortness of breath and intermittent left flank pain for the past 2 to 3 days is brought by her family for evaluation. The dyspnea worsens when she lies down. She denies chest pain, back pain, and syncope. She has also had mild nonbloody diarrhea of 2 days’ duration but no vomiting or oral intake intolerance.

For 2 weeks, a 49-year-old woman has had mild, intermittent epistaxis with left-sided facial pain, swelling, and otalgia; the severity of the bleeding has increased during the past 24 hours. She also has congestion of the left naris of 1 month's duration.

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A 26-year-old otherwise healthy man presents to the emergency department with a 3- to 4-hour history of left-sided chest pain. The pain is pleuritic and accompanied by nausea and discomfort in the left arm.

A 23-year-old man presents to theemergency department (ED) withacute chest discomfort, which startedin the morning. He describes the discomfortas more akin to palpitationsthan to actual pain. The discomfortis midsternal, nonradiating, nonpleuritic,and associated with dyspnea; itis neither exertional nor positional.There is no viral prodrome.