Cardiovascular Disease

A network of purplish pink lesions recently developed on a 28-year-old woman’sarms and legs. The asymptomatic rash becomes more prominent with exposureto cold. The patient denies fever, aches, arthralgias, oral erosions, chestpain, and photosensitivity.

Three weeks after coronary artery bypass graft (CABG)surgery, a 52-year-old woman complained of pain at thesternal scar. The patient had a history of diabetes and hypertension.She had smoked cigarettes for many years.

A 72-year-old woman presented to the emergency department with epistaxis and generalized telangiectasia. The patient was known to have Rendu-Osler-Weber syndrome, or hereditary hemorrhagic telangiectasia, an autosomal dominant disorder that is associated with arteriovenous fistulae of many organs.

In a 65-year-old man with a family history of colorectal carcinoma, an initial screening coloscopic examination revealed 2 arteriovenous malformations. These delicate red lesions with a vascular network and irregular edges were found in the cecum.

Many patients who present to the emergency department(ED) with severe headache request a narcotic to relieve thepain.

A 59-year-old woman presented for a routine physical examination. She had no physical complaints and took no medications. During the physical examination, bilateral, flat, slightly elevated, yellowish cutaneous lesions were noted above and below the skin folds of the patient's eyelids.

A 54-year-old man is admitted to the hospital because of worsening lower extremityswelling and knee and ankle pain and stiffness. These symptoms havemade walking very difficult for the past month.

The family of a 50-year-oldalcoholic man brings him to youroffice. They are concerned abouthis health and note that they had notseen him for several months beforehe reappeared. The patient complainsof generalized weakness, fatigue, andbleeding gums.

For the past several weeks, a 54-year-old man has had progressivelyworsening abdominal pain and general achiness.He has no nausea, vomiting, diarrhea, or fever and no historyof trauma.

For the past 3 months, a 72-year-old man has had progressivelyworsening dyspnea on exertion and constantvague discomfort in the left chest that appears to have apleuritic component. He denies paroxysmal nocturnaldyspnea and has no history of chest trauma. However, hehas a chronic cough that sometimes produces purulentsputum-although it is not associated with hemoptysis.His feet swell occasionally, and he has mild anorexia andhas lost 20 lb in 6 months.

A 76-year-old woman is admitted to the hospital for increasing fatigue and weaknessthat began about 3 weeks earlier. Her symptoms have worsened duringthe past week to the point of profound weakness and both dyspnea and nearsyncopewith minimal exertion.

In their case report, “Sudden Headache in a Woman With Hypertension” (CONSULTANT,July 2002, page 1049), Drs Gary Quick and Maggie Law describe apatient with uncharacteristically severe headache and very high blood pressure.

Patients as young as 20 years need to be evaluated forcardiovascular risk factors, according to recently updatedrecommendations from the American Heart Association(AHA).1 In addition, the risk of heart disease should beassessed every 5 years in persons aged 40 or older andthose with multiple risk factors.

A Young Boy With High Fever and LethargyA 5-year-old boy is brought to the emergency department(ED) by his parents. They report that, for thepast week, the child has had a high fever (temperatureup to 40oC [104oF]), generalized weakness, lethargy, andlack of appetite. The boy’s eyes are bloodshot and he hasrefused food and drink. The child has no history ofcough, shortness of breath, hematemesis, melena, headaches,vision problems, or seizures. He has not been incontact with sick persons, has not traveled abroad, doesnot have a pet, and is not taking any medications. His immunizations are up-to-date.

A 53-year-old man has hadmalaise, intermittent cough, and occasionalfever and night sweats for 2weeks. He has also lost some weightduring this time but denies hemoptysisand sputum production; he hasnot traveled abroad recently. His onlysignificant medical condition is hypertension,which is well controlled withmedication.

How critical-and cost-effective-is in-officepulmonary function equipment for the primarycare practitioner?

A 41-year-old woman has had a 2-week bout of nausea, vomiting, and diarrhea.Her history includes chronic hepatitis C and alcohol abuse. She also has orthostatichypotension. A baseline ECG is obtained.

For 2 months, a 47-year-old woman experienced constipation, weakness, fatigue, and dry skin. She also complained of moderate weight gain and menorrhagia during the same period. The patient took no medications and denied any allergies.

A 78-year-old man presented to theemergency department with a 3-weekhistory of progressive shortness of breathand cough with blood-streaked, yellowishsputum. The patient had dyspnea onexertion limited to 2 blocks, 2-pilloworthopnea, paroxysmal nocturnal dyspnea,and nocturia. Neither fever norchills were present. He had lost 7.2 kg(16 lb) during the last year.

Smoking-related diseases have reached epidemic levelsamong women in the United States. Since 1980, neoplastic,cardiovascular, respiratory, and pediatric diseases attributableto smoking-as well as cigarette burns-havebeen responsible for the premature deaths of 3 millionAmerican women and girls. Lung cancer is now the leadingcause of cancer-related deaths among US women; itsurpassed breast cancer in 1987.1

Calcium channel blockersare commonly prescribedto treat severalcardiovascular diseasesand may be helpful inother conditions, such as migraineand bipolar disorder.1 These agentsare associated with numerous clinicallysignificant drug interactions.1-3While some of these interactions,such as the effect of verapamil onserum digoxin concentrations, arewell-known, others are not widely recognized-yet warrant attention.

A 48-year-old woman was admitted to the hospital with deep venous thrombosis of the right leg. She had a history of non-Hodgkin lymphoma, which was in remission. The patient had been a heavy smoker for many years.

A 69-year-old retired accountant presents with a 2-month history of daily headaches. The pain is moderate, constant,global, pressure-like, and occasionally pulsating; it is sometimes exacerbated when the patient lies down. He denies nauseaor vomiting, ocular symptoms, weakness, or sensitivity to light. His wife reports that years ago he experienced throbbingheadaches regularly.

During a routine office visit, a 64-year-old woman who has had type 2 diabetesfor more than 10 years complains of increased pedal edema. The edema is minimalon awakening and worsens throughout the day.

My patient is a 42-year-old woman who experienced a nonblanching, purpuricrash and edema of the lower legs after she started taking nifedipine (Figure).

Although acute low back pain usuallyresolves within 6 weeks-with or withouttreatment-the pain may signal asignificant neurologic or life-threateningdisease that warrants immediateintervention.

More than1.8 millioncardiaccatheterizationsandat least 600,000 percutaneoustransluminal coronaryangioplasty (PTCA)procedures are performedin the United States annually.1 The use of these diagnosticand interventionalmodalities continues togrow even as financial constraintsincrease. Yet formany patients with coronaryartery disease (CAD),medical therapy may be anappropriate option.

Drs Sonia Arunabh and K. Rauhilla’s case of a 62-year-old woman with Raynaud’sphenomenon (CONSULTANT, September 15, 2001, page 1526) offers one ofthe finest photographs of this condition that I have seen (Figure).

A 72-year-old man sought medical evaluationafter he awoke and was unableto open his right eyelid (A). He deniedpain, recent trauma, and diplopia. Thispatient’s history included well-controlledhypertension and hypercholesterolemia,for which he was taking atorvastatin.He did not have diabetes.

For 2 days, a 68-year-old woman had watery, yellowish diarrhea with mucus and left lower quadrant pain. Her medical history included hypertension, diabetes mellitus, and congestive heart failure (CHF); she had left the hospital 5 days earlier following treatment of an exacerbation of CHF with intravenous furosemide and sodium and fluid restriction. The patient was taking furosemide, lisinopril, and glipizide; she denied any recent antibiotic therapy.