Cardiology

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.

Ten weeks before presentation, this55-year-old woman noticed decreasedsensation in her feet and a bluish discolorationof her toes. These symptomsprogressed rapidly, and pain andcoldness in both feet increased in intensity.Her feet subsequently becamegangrenous. Her seropositive arthritishad been diagnosed about 6 yearsearlier. The disease had been wellcontrolled until about 10 weeks beforethis photograph was taken.

Is hypertension a frequent manifestation of thyroid disease?Which clinical clues suggest hypertension in persons with thyroiddysfunction?

An 86-year-old woman had noted intermittent, transient “shading” and “hazing” of the vision in her right eye. Her best corrected vision in that eye was 20/20. She had pseudophakia from past cataract surgery.

An 87-year-old woman complained ofseeing a red tinge on the wallpaper inher house through her right eye. Thepatient had mild memory loss andmoderate hypertension, for whichshe took atenolol. She had quit smokingcigarettes many years earlier.

During an annual eye examination, a 65-year-old womanwith a 5-year history of type 2 insulin-dependent diabetescomplained that her vision had slightly worsened in botheyes. Her best corrected visual acuity was 20/30 in botheyes.

Sudden profound vision loss in her left eye prompted an82-year-old woman to seek evaluation. She also complainedof “just not feeling well” and reported new-onsettemporal and occipital headaches of 6 weeks’ duration.

A 49-year-old woman presented for aroutine eye examination. She had nohistory of systemic disease and tookno medications.

Q:Which combinations of antihypertensivemedications are most effective-and which arebest avoided?

Examine patients’ carotid arteries immediatelyafter you examine theirlungs.

Diffuse petechiae suddenly arose on the back and abdomen of a 79-year-old woman. Within several days, the asymptomatic lesions covered her arms and face as well.

A healthy 32-year-old scuba diver was taken to the emergency department (ED). He had lost consciousness following a dive in which he had held his breath during a rapid ascent to the surface and had performed the Valsalva maneuver to clear his ears.

A slightly pruritic, red, scaly rash on an 8-year-old boy’shands has been progressively worsening since it appeared4 months earlier. Nail pitting also was noted. There are noother rashes on his body. The patient is active in sports;denies any new exposure to soaps, clothing, or other contactants;and spends time in the homes of his recently divorcedparents.