Cardiology

A 35-year-old man, a smoker, had right pleuritic pain, productive cough, and fever for 3 days. His pulse rate was 107 beats per minute; respiratory rate, 14 breaths per minute; blood pressure, 136/80 mm Hg; and temperature, 37.7°C (99.9°F). There were signs of right upper lobe consolidation. Laboratory studies showed hyponatremia. Chest films showed a homogeneous density in the right upper lobe.

A 71-year-old man, who had recently returned from a month in Europe, complained of left lower leg swelling and pain of 1-week's duration. For many years, this obese patient had chronic venous insufficiency of both legs and chronic osteoarthritis of the knees that severely limited his ability to walk. The patient was admitted to the hospital with extensive cellulitis of the left lower leg.

This 8-year-old girl presented with bilateral ptosis, down-slanting palpebral fissures, malar hypoplasia, mild micrognathia, and mild webbing of the neck. She also had marked lumbar lordosis and a dextroconvex thoracic scoliosis with scapular winging. There was a generalized reduction in muscle mass with proximal limb weakness, short stature, diminished deep tendon reflexes, and an awkward waddling gait.

A 61-year-old woman who was receiving dialysis for diabetes-associated end-stage renal disease was hospitalized for care of an abdominal wound that had been debrided and closed. At this time, the patient had several large, indurated, red plaques with central, stellate, black eschars on her abdomen, left buttock, and legs. An early focus of ulceration was noted superior to the stapled incision.

Having suffered progressive shortness of breath for 2 years, a 35-year-old man was eventually hospitalized. The patient's dyspnea had worsened over the past year, but he had neither chest pain nor palpitations. His primary care physician first noticed finger clubbing 8 months ago.

A 41-year-old man complaining of left-sided chest pain for 2 hours was examined in the emergency department (ED). On arrival, his blood pressure was 160/100 mm Hg; heart rate, 90 beats per minute; respiratory rate, 18 breaths per minute; oxygen saturation, 99%; and temperature, 37.2°C (99°F).

Police brought a delirious, combative 24-year-old man to the emergency department. The patient was unable to provide any history on arrival, but his scarred, blistering lips and his vital signs (blood pressure, 166/102 mm Hg; heart rate, 97 beats per minute; respiratory rate, 24 breaths per minute; and temperature, 38.2°C, or 100.9°F) led to a possible diagnosis of cocaine-induced delirium.

An 80-year-old woman presented with recurrent abdominal pain for 1 month, constipation, and vomiting. She had no diarrhea, rectal bleeding, or weight loss.

A 49-year-old woman with a history of alcoholic cirrhosis, esophageal varices, coronary artery disease, diabetes mellitus, and hypertension presented to the emergency department with a 2-day history of fever, chills, nausea, and back and abdominal pain. The pain began on the right side, progressed to the lower back, and radiated into the right anterior thigh and groin area.

A 52-year-old man from Bangladesh had suffered from pleuritic pain for 1 week. He had never had tuberculosis and-except for being a cigarette smoker-had no notable medical history. The only remarkable findings were a temperature of 37.5°C (99.5°F) and anterior tenderness over the right lower rib cage. Laboratory test results were normal. A tuberculin test with 5 TU of purified protein derivative produced positive results, with a 15 × 17-mm induration.

A 63-year-old man was given oral celecoxib, 100 mg bid, for shoulder pain. Three days later, a pruritic rash appeared on his back, then spread to the chest, lower legs, and face. He stopped the celecoxib on his own and self-administered diphenhydramine for the pruritus. The rash and itch persisted, which prompted the patient to seek medical care. He had no respiratory symptoms.

A 45-year-old man with a history of congestive heart failure presented with cough and dyspnea. A chest roentgenogram showed loculated pleural effusion in the horizontal fissure of the right lung, and a CT scan revealed pleural-based density in that lung.

A 19-year-old man was admitted to the hospital with malaise, fatigue, and intermittent fever (temperature of 38°C [100.4°F]) for the last 2 weeks. Physical examination revealed scarce purpuric lesions over the lower extremities; a pericardial friction rub was audible over the precordium when the patient was supine and seated, and the spleen was remarkably enlarged.

Levofloxacin, 500 mg/d, had been prescribed for a 74-year-old woman who had a urinary tract infection. The patient had type 2 diabetes and hypertension. She was allergic to sulfa drugs.

This rash, which covered a 68-year-old woman's body, was noted to have worsened during the past 2 months. A cephalosporin antibiotic had failed to clear the condition. The patient, a nursing home resident, suffered from emphysema, asthma, and heart disease. She had been receiving oxygen therapy and prednisone for 1 year.

A 73-year-old man was admitted to the hospital with pain in his hands, feet, and elbows. The patient, an alcoholic, had a 20-year history of hypertension and diabetes. Deformities of the hands and feet had developed during the past 5 years. Tophi were present over both ear lobes. The serum uric acid level was 15 mg/dL.

A 71-year-old woman was brought to the hospital with blunt abdominal trauma suffered in an automobile accident. She complained of pain in the chest and abdomen.

A 72-year-old woman who had fallen and injured the left side of her chest came to the emergency department complaining of pain in that area. She was physically stable and not short of breath. A soft systolic murmur was heard over the left precordium; the lungs were clear. A posteroanterior chest film showed no rib fracture but it did show an enlarged heart and a large, calcified ventricular aneurysm.

A 56-year-old man was admitted to the hospital with right lower lobe pneumonia, which was exacerbated by smoking-induced chronic obstructive pulmonary disease (COPD).

An 80-year-old man with a history of congestive heart failure, coronary artery disease, cardiomyopathy, and thoracic and abdominal aneurysms was taken to the emergency department because of mental status changes, back pain, and ecchymotic areas over his body. The ecchymoses started on his back 5 days before admission and spread to his abdomen.

A 97-year-old woman with a history of hypertension and a paraesophageal hiatal hernia presented with abdominal distention and shortness of breath. Three days earlier, she had fallen and sustained a hairline pelvic fracture; she was evaluated in the emergency department and given narcotics for the pain. Subsequently, the patient's abdomen became increasingly distended, and she had no bowel movement for 3 days.

During the assessment of an 83-year-old man who had an infected arteriovenous graft, chest films showed a masslike density in the lower right hemithorax.

An obese 56-year-old woman was hospitalized after 2 days of chest pain, shortness of breath, and palpitations. Physical examination revealed no abnormalities, and serial cardiac enzyme studies and an ECG ruled out myocardial infarction. However, transesophageal echocardiography showed a lesion in the mediastinum.

The parents of a 2-year-old boy with a 3-day history of fever took him to the emergency department. The child's temperature fluctuated between 38°C (100.4°F) and 39°C (102.2°F). As part of the workup, chest films were taken.

An 82-year-old woman was admitted to the hospital with severe dilated cardiomyopathy. The condition was alcohol-induced and had been diagnosed about 12 years earlier. The patient was taking angiotensin-converting enzyme inhibitors and diuretics.

This 63-year-old woman's primary care physician had referred her to an ophthamologist because of her persistently red eye. She had been treated unsuccessfully for almost 3 weeks with several different antibiotic eyedrops. Her vision had begun to worsen, and she started to hear “swishing” noises. Pertinent medical history included a carotid endarterectomy on the same side as the red eye about 1 month before onset of the symptoms.

A 79-year-old nursing home resident was hospitalized for evaluation of hyperkalemia and leukocytosis. Her medical history included hypertension, respiratory failure with subsequent tracheostomy placement and ventilator dependency, and anemia. Both of her legs had been amputated above the knee secondary to complications of type 2 diabetes mellitus.

The mother of a 7-year-old boy with cardiofaciocutaneous syndrome sought treatment for the cutaneous aspects of her son's disease. Dry skin and keratosis pilaris of the upper outer arms were noted.

Redness, irritation, and diplopia developed over 2 to 3 weeks in a 55-year-old man's left eye. The injection worsened and was unresponsive to eye drops. Ptosis, mild proptosis, and elevated intraocular pressure developed. A bruit was auscultated over the affected eye.

A 21-year-old woman had suffered recurrent nosebleeds and pain in her nose for the previous 2 months. Physical examination revealed an extremely vascular, slowly enlarging intranasal growth on the anterior surface of the septum.