Patient Presentations

hypertriglyceridemia

17-year-old female brought in by her parents to check her cholesterol due to family history of hypertriglyceridemia. Her dad and paternal aunt have history of pancreatitis. Family history is negative for premature arteriosclerotic cardiovascular disease. Her cholesterol panel is as following: Total cholesterol 188 mg/dL (<200), triglyceride 851 mg/dL (<150), HDL 15 mg/dL (>50), LDL 102 mg/dL (<130).

Sinus Arrhythmia

18-year-old student radiographer presents with a five-month history of blackouts which had latterly been occurring three or four times a day. They invariably occurred when she was standing, and from her description, there was no reason to think that the blackouts were other than vasovagal attacks, but their frequent occurrence was inconvenient. There were no other symptoms and no previous medical complaints. The pulse rate was 60 beats per minute and irregular; blood pressure was 100/60 mmHg with no postural drop. A three-minute electrocardiogram recorded during spontaneous respiration showed respiratory sinus arrhythmia with an amplitude of 20-1%, well outside the normal range.

patent ductus arteriosus

2-week-old infant with a history of prematurity presents with a pink torso and upper extremity and blue lower extremities. On cardiac auscultation, you notice a rough, continuous "machinery murmur" heard over the left sternal border at the 2nd intercostal space (pulmonary area).

tetralogy of fallot

2-week-old newborn brought to the ER by his mom who reports a sudden loss of consciousness during feeding and with crying. She also has noticed that the infant's lips have turned blue on three occasions during feeding. blood pressure is 75/45 mmHg, a pulse is 170/min, and respirations are 44/min. A grade 3/6 harsh systolic ejection murmur is heard at the left upper sternal border. A CXR shows a small boot-shaped heart and decreased pulmonary vascular markings.

vasovagal hypotension

22-year-old female comes to the emergency department for a syncopal episode. Just prior to the syncopal episode, the patient experienced painful menstrual cramping. She experienced a cold sweat and palpitations with the cramping. The patient describes similar episodes to her menstrual cramps in the past. Her vital signs and physical examination are normal. ECG is unremarkable.

mitral valve regurgitation

22-year-old female who complains of generalized, sub-sternal chest pain that is worsened with exertion. She appears anxious; she denies ETOH, tobacco and illicit drug use. You auscultate her heart and hear a midsystolic click

cardiac tamponade

22-year-old male is brought to the emergency room after sustaining a stab wound in the chest. He reports shortness of breath. On physical examination, his vital signs are a temperature of 37 C, heart rate 121 bpm, blood pressure 90/60 mmHg, respiratory rate 20 rpm, and oxygen saturation 99% on room air. Physical examination is significant for muffled heart sounds and a drop of BP > 10 mm Hg systolic with inspiration. You note his neck veins are distended. He does not respond to aggressive fluid resuscitation. You order a chest x-ray and the EKG reveals low voltage QRS complexes and electrical alternans.

premature beats

24-year-old college student complaining of a feeling as though his heart is momentarily stopping followed by a feeling of his heart in his throat. He appears anxious and reports a weight loss of about 7 lbs over the past 3 months. On auscultation of his heart, you notice an occasional skipped beat, followed by a brief pause and then a regular rhythm. His laboratories reveal a TSH of 0.001 and on his EKG you notice a wide, bizarre QRS complex, greater than 0.12 sec and no identifiable p wave.

pulmonary regurgitation

24-year-old male with dyspnea on exertion. Physical exam reveals a high pitched decrescendo murmur at the LUSB that increases with inspiration

paroxysmal supraventricular tachycardia

25-year-old female patient with complaints of sudden onset of a pounding heartbeat, which is regular and "too rapid to count." She reports that the episodes begin and terminate abruptly and are associated with shortness of breath and chest discomfort. On exam the patient appears anxious, her heart rate is 170 bpm. EKG demonstrates a shortened PR interval, widened QRS, and delta waves.

pulmonary stenosis

25-year-old male who presents to the clinic complaining of mild dyspnea on exertion. Examination reveals a prominent jugular pulsation and a palpable parasternal lift. There is a harsh systolic murmur best heard at the second and third left intercostal space; it radiates to the left shoulder. An early systolic sound precedes the murmur during expiration. ECG demonstrates right-axis deviation

hypertrophic cardiomyopathy

25-year-old woman presents the ER after a syncopal episode. She had a loss of consciousness 3 times over the past 12 months. Each event occurred during or just after physical exercise. On PE: BP 110/70 mm Hg, HR 75/min, normal S1/S2, and an III/VI systolic ejection murmur is heard best at the left sternal border that decreases with squatting. The EKG shows a normal sinus rhythm with diffuse increased QRS voltage.

dilated cardiomyopathy

28-year-old Caucasian female complaining of a one-week history of fatigue, progressively worsening shortness of breath, and swelling of her feet and ankles. She denies any chest pain. PMH unremarkable except for a recent cold two weeks prior. No past SHx. OCPs only med. She denies any recreational drug use. On PE, her temp is 37 C (98.6 F), BP is 120/70 mmHg, pulse is 84/min, and respiratory rate is 20/min. Her PE is also notable for bibasilar crackles, JVD, an S3 gallop (heard below), and 2+ pitting edema up to the ankles bilaterally. Her electrolytes and complete blood count are within normal limits. CXR reveals cardiomegaly with pulmonary congestion, EKG shows nonspecific ST and T wave changes, and echocardiography demonstrates left ventricular dilation and dysfunction and low cardiac output.

bundle branch block

32-year-old male presents to your clinic for evaluation of a recent onset of dizziness that occurred while he was upright and was generally associated with exertion. This especially concerned him since he was working as a bricklayer. During one episode at work, he found himself down on the floor but was not sure if he actually passed out. The patient smokes one pack of cigarettes per day and drinks four to six beers daily on the weekend. On physical examination, his blood pressure is 145/88 and his HR is 64 bpm and regular. He is modestly overweight, with a distribution of fat consistent with a beer belly. A 12-lead ECG showed sinus rhythm, rate 60, with an R and R' (upward bunny ears) in V4-V6. There were no previous ECGs immediately available.

ventricular septal defect

4-year-old boy who is brought to your office by his parents because he gets tired very easily and cannot keep up with the other children. On exam, you hear a loud, harsh, holosystolic murmur at the left lower sternal border without radiation to the axillae.

secondary hypertension

42-year-old woman complaining of poor sleep. She has also been feeling restless and agitated for several months. Upon further questioning, she reveals that she has also been suffering from headaches and has gained 18 pounds over the same time period. She denies any chest pain, palpitations, diaphoresis, or increased appetite. She has no significant past medical history other than two uncomplicated pregnancies resulting in normal spontaneous vaginal deliveries. She denies any tobacco, alcohol, or illicit drug use. Her vital signs show Temp 37 C (98.6 F), BP 164/112 mm Hg, HR 88/min, and RR 12/min. Physical exam shows an overweight woman with no palpable thyroid nodules or abnormalities on cardiopulmonary exam. Laboratory evaluation reveals the following: Sodium 141 mEq/L, potassium 3.1 mEq/L (normal 3.5-5.0), chloride 96 mEq/L, bicarbonate 25 mEq/L, BUN 10 mg/dL, creatinine 0.8 mg/dL, glucose 220 mg/dL, and calcium 9.5 mg/dL.

essential hypertension

44-year-old Caucasian man with a four-year history of diabetes mellitus presents to your office for a routine check-up. He has no complaints. His medications include metformin, aspirin, and a multivitamin. He works as an insurance salesman and has a sedentary lifestyle. He smokes one pack of cigarettes per day and drinks two cans of beer on weekends. He denies any illicit drug use. His diet includes mostly meat and large amounts of "junk food." On physical exam, his blood pressure is 157/96 mmHg, heart rate is 82 bpm. His BMI is 34.2 kg/m^2. The remainder of his physical exam is unremarkable. Laboratory studies reveal an HbA1c of 7.8%. At his last check-up one month ago, his blood pressure was 151/93 mmHg.

sick sinus syndrome

45- year-old male admitted to the hospital because of several months of sudden onset of recurrent weakness accompanied by flushing of the face and dizzy spells. The patient also had recurrent spells of chest pain localized to the sternal area. The symptoms last for 10-15 seconds and sometimes 30 seconds to a minute and go away without treatment. During his stay in the ICU, the patient had similar symptoms several times and the monitor showed long periods of asystole with no ventricular activity. This was associated with blood pressure drops and the patient felt dizzy. The echocardiogram is within normal limits.

acute endocarditis

45-year-old female with a long history of a heart murmur with one week of increasing fatigue and low-grade fevers. She had a dental cleaning two weeks ago. She denies any hematuria, neurological symptoms, or changes in the appearance of her hands and fingernails. Her past medical history is otherwise insignificant. On physical exam, her temperature is 38.1 C (100.6 F), heart rate is 92/min, blood pressure is 118/67, and respiratory rate is 16/min. She appears fatigued but in no acute distress. Cardiac auscultation reveals a grade III/VI holosystolic murmur heard best at the cardiac apex in the left lateral decubitus position. Pulmonary, abdominal, and extremity exams are within normal limits. An echocardiogram is performed and is shown here. The patient is admitted and started on empiric IV antibiotics. Three days later, 4/4 blood cultures grow Streptococcus viridans that is highly sensitive to penicillin.

torsade de pointes

46-year-old female with a history of alcohol abuse is brought to the emergency room for altered mental status. Physical examination reveals a cachectic appearing female, normal breath sounds, and normal heart sounds without murmurs. In the emergency room she becomes completely unresponsive for 1 minute and her blood pressure decreases to 50/30.

acute pericarditis

48-year-old male with type I diabetes mellitus and end-stage renal disease currently on hemodialysis with dyspnea, cough and chest pain. He describes the pain as worse during inspiration and when he is lying on his back. The patient reports significant relief oh his chest pain with sitting up or leaning forward. A basic metabolic panel is remarkable for a BUN > 60 mg/dL. On cardiac auscultation, you hear a pericardial friction rub that is heard best when the patient is upright and leaning forward. The EKG demonstrates diffuse, ST-segment elevations in the precordial leads.

Phlebitis/Thrombophlebitis

49-year-old male who is being evaluated for pain and swelling of his right lower extremity. He noticed his calf appears red and denies any trauma to the affected area. A week prior to presentation, he was on a plane for over 13 hours. Medical history is significant for venous insufficiency. On physical exam, there is erythema on the posterior calf and tenderness along the course of a superficial vein. A duplex ultrasound demonstrates impaired blood flow and incompressibility of a superficial vein.

stable angina

50-year-old woman with a history of hyperlipidemia and diabetes type 2 complaining of "chest pain attacks." She says that these attacks tend to occur while walking up five flights of stairs to get to her apartment, they last for 15-20 minutes and are relieved by rest. She describes the pain as sharp and substernal. A baseline EKG is unremarkable. Suspecting the diagnosis, you perform an exercise stress EKG and observe transient ST depressions in the anterolateral leads after significant exertion.

hypercholesterolemia

55-year-old obese Caucasian gentleman who arrives at your clinic for a routine check-up after having some blood work done during a routing workplace health screening. He is found to have a total cholesterol level of 430 mg/dL. He complains of calf pain while walking to the convenience store, which only resolves with rest. He states that he has a follow-up appointment with his cardiologist because of some occasional chest pain and abnormalities seen on his EKG. Additionally, you notice that he has well demarcated yellow deposits around his eyes.

arterial embolism

56-year-old male with a known history of polycythemia suddenly complains of pain and paresthesia in the left leg. Physical examination reveals the left leg is cool to the touch and the toes are cyanotic. The popliteal pulse is absent by palpation and Doppler. The femoral pulse is absent by palpation but weak with Doppler. The right leg and upper extremities have 2+/4+ pulses throughout.

hypertensive emergency

57-year-old female with complaints of a severe headache, vomiting, neck stiffness, and chest pain that has developed over the last several hours. Physical examination is significant for papilledema, but no focal neurologic defects are noted. The patient is afebrile and vital signs are the following: pulse is 88/min, blood pressure is 200/140 mmHg, respirations are 20/min, and SpO2 is 97% on room air. A head CT is obtained and is shown here. Urinalysis reveals gross hematuria and proteinuria.

NSTEMI

58-year old obese male who is brought to the emergency department with severe substernal chest pain of one hour's duration. The patient was taking a morning walk when the onset of pain led him to seek care. His past medical history includes coronary artery disease, hyperlipidemia, and hypertension. Medications include aspirin, losartan, and atorvastatin. An electrocardiogram reveals T-wave inversions in leads II, III, and aVF and ST depressions in V5 and V6. The basic metabolic panel and complete blood count were within normal limits. A point-of-care troponin I level was elevated at 1.8 ng/mL

restrictive cardiomyopathy

58-year-old man complaining of several months of worsening shortness of breath and ankle swelling. He denies palpitations, lightheadedness, syncope, or chest pain. PMH significant for hereditary hemochromatosis. On physical exam, his temperature is 37 C (98.6 F), pulse is 78, blood pressure is 130/72 mm Hg, and respiratory rate is 16. He has elevated jugular venous pressure, diminished breath sounds at the lung bases, tender hepatomegaly, and bilateral pitting ankle edema. There are no murmurs, rubs, or gallops. EKG shows low-voltage QRS complexes without any signs of ischemia. His chest x-ray shows a normal sized heart and bilateral pleural effusions. Echocardiography shows symmetrical thickening of the left ventricle, normal left ventricular volume, and mildly reduced systolic function.

unstable angina

58-year-old man with a history of coronary artery disease, hypertension, and hyperlipidemia presents to an emergency department for evaluation of chest pain. He reports somewhat suddenly experiencing dull left-sided chest discomfort while at rest at home that was not relieved with taking nitroglycerin. His vital signs are T 37.1, HR 94 beats per minute, BP 133/87, and O2 saturation 97% on room air. His ECG shows no ST-segment changes; serum troponin is not elevated. His chest pain subsequently resolves and he is admitted to the cardiac service for further management

aortic stenosis

59-year-old male with chest pain, dyspnea, and presyncope. The symptoms occurred after climbing a flight of stairs. He has a late systolic-ejection murmur (SEM) heard in the second intercostal space (ICS) at the right sternal border with radiation to the carotids and the apex. The murmur is decreased with Valsalva maneuver. EKG is suggestive of LV hypertrophy.

aortic regurgitation

61-year-old male presents with a recent history of increased fatigue with mildly increased exertional dyspnea. Patient denies any significant past medical history but states that he had some heart problems as a child, though he was never clear as to what was the problem. On cardiac examination, you hear an early diastolic, soft blowing decrescendo murmur with a high pitch quality, especially when the patient is sitting and leaning forward. No thrill is felt.

AV malformation

63-year-old illiterate female with a history of right motor partial seizures and generalization since the age of 23 years arrives at the emergency room due to acute right hemiparesis. Neurological examination reveales a right hemiparesis, right tactile and pain hypoesthesia, poor fluency, temporal and spatial disorientation, and a Mini-Mental State Examination score of 5 points (one for immediate memory, two for naming, one for repetition, and one for commands). MRI is performed demonstrating a massive AVM in the left hemisphere of the frontotemporoparietal region (9.2 × 6.0 cm) with parenchymal compression and microangiopathy.

PAD

63-year-old male complaining of bilateral leg pain, which has been increasing gradually over the past several months. It worsens when he walks but improves with rest. Past medical and surgical history is significant for hypertension, hyperlipidemia, and coronary artery bypass graft (5 years ago). He has a 60-pack-year smoking history. Vital signs are as follows: Temp 37C, HR 70, BP 143/89, and RR 18. Physical exam of the lower extremities reveals palpable but weak posterior tibial and dorsalis pedis pulses bilaterally; they are warm and well perfused. Ankle-brachial indices are 0.7 and 0.8.

pericardial effusion

64-year-old female who reports five weeks of occasional shortness of breath and pain radiating from the shoulder to the chest. The patient reports that the pain is worse with inspiration and lying down and is relieved by sitting forward. On physical exam you note distant heart sounds. Her EKG shows low voltage QRS complexes and electrical alternans.

mitral regurgitation

64-year-old obese man with a history of hyperlipidemia and poorly controlled type 2 diabetes underwent percutaneous transluminal coronary angioplasty of the posterior descending artery 3 days ago for an ST-elevation myocardial infarction. He has so far been stable since this procedure, but overnight you are called to his bedside. He is pallid and breathing laboriously. Notable vital signs include a blood pressure of 85/45 mmHg with a heart rate of 125 beats per minute. His lung exam is notable for bibasilar crackles. On cardiac exam, you note a hyperactive precordium with a new III/VI blowing holosystolic murmur at the apex (mitral area) with a split S2 that radiates to the axilla.

Prinzmetal angina

65-year old man who presents to the ED at 1 am with 90 minutes of central chest pressure that awoke him from sleep. He says he thinks he has 'indigestion.' The pain is non-radiating, with mild shortness of breath but no nausea, vomiting or diaphoresis. He is an ex-smoker with a 20 pack-year history. There is no previous history of CAD, diabetes, hypertension or high cholesterol. On arrival, he looks well, with normal heart rate (54 bpm), blood pressure (127/86) and oxygen saturation (98% on room air). His pain has improved slightly with sublingual nitrates in the ambulance, although he still has some ongoing chest discomfort. His ECG is shown below. Troponins are positive. He is admitted to hospital and undergoes emergent cardiac catheterization, where he is without obstructive coronary disease, but his symptoms can be provoked with the administration of intravenous ergonovine.

Atrial fibrillation/flutter

65-year-old woman with palpitations. Her past medical history is notable for chronic obstructive pulmonary disease (COPD) for which she has been hospitalized once in the last year. On exam her T 98.4F, HR 86, BP 105/70, RR 18, SpO2 94% on room air consistent with her baseline. The ECG demonstrates low-amplitude fibrillatory waves without discrete P waves and an irregularly irregular pattern of narrow QRS complexes

giant cell arteritis

67-year-old female with a severe throbbing headache and visual impairment in the left eye. The patient describes worsening of pain with chewing or combing her hair. Lately, she reports feeling very weak and tired especially in the mornings. At times she cannot even raise her arms to reach the cabinets in her kitchen. On physical exam, she has decreased visual acuity of the left eye, scalp tenderness on the left, and an absent pulse in the left temporal area. Laboratory testing is significant for an elevated erythrocyte sedimentation rate. She is admitted and immediately started on systemic glucocorticoids.

ventricular tachycardia

68-year-old female who arrives at the emergency department after a syncopal episode at work. Physical exam reveals an obese, unresponsive female with bilateral nonpalpable radial, carotid, and distal pedal pulses. Vital signs are as follows: T 99.4 F and BP 88/47.

AV block

68-year-old male with complaints of "a fluttering sensation in the chest", dizziness, and a syncopal episode earlier today. Vital signs are as follows: T 98.8 F, HR 40 (irregular), BP 90/56, RR 28, O2 Sat 95% RA. The physical exam is significant for a weak pulse, widened pulse pressure, crackles auscultated at the bilateral lung bases, and cannon a-waves noted at the internal jugular veins.

STEMI

70-year-old male complaining of left-sided crushing substernal chest pain that began suddenly while he was walking his dog. He denies any past medical history, has not seen a physician recently and has smoked one pack per day for the past 50 years. Vital signs are BP 85/50 mmHg, HR 50 bpm, RR 22, T 99.1 deg F. Physical exam shows an obese, nervous man with jugular venous distension and clear lung fields. An electrocardiogram shows ST elevations in II, III, and aVF. The echocardiogram showed marked motion abnormalities in the inferior posterior, lateral wall. An initial troponin I was 238 ng/ml (normal range 0-2.5 ng/ml). The patient was taken for emergent cardiac catheterization. This demonstrated an occluded right coronary artery that was opened with primary angioplasty and stent placement.

orthostatic hypotension

71-year-old man with a history of BPH is hospitalized for an ST-elevation myocardial infarction and undergoes percutaneous coronary intervention. Upon discharge, he is prescribed aspirin, clopidogrel, prazosin, isosorbide mononitrate, carvedilol, enalapril, and atorvastatin. One week after discharge her presents to your office with complaints of faintness, lightheadedness, dizziness, confusion, and blurred vision that occur within seconds to a few minutes of standing and resolve rapidly on lying down. On physical examination, you note a drop of > 20 mm Hg systolic and 10 mmHg diastolic after a change from supine to standing.

mitral stenosis

72-year-old female who presents to your office for a routine check-up. While she otherwise feels well, it has been a long time since she last received medical care. On exam her you note an apical, rumbling diastolic murmur with a split s1 that occurs following an opening snap. The rumbling is loudest at the start of diastole and is heard best at the left sternal border and apex (mitral area). She has no other physical exam findings and has no other past medical history.

ventricular fibrillation

72-year-old male who develops coarse ventricular fibrillation while being monitored following an uneventful colonoscopy. He is immediately defibrillated using a bi-phasic defibrillator at 120 joules. The countershock is successful and he is converted to a sinus tachycardia. He has resumed spontaneous breathing.

aortic aneurysm

73-year-old female with a history of hypertension, diabetes, and coronary artery disease presents to the emergency department with severe, tearing, knife-like back pain. She states that the pain started approximately 30 minutes ago and she has felt lightheaded and dizzy ever since its onset. On exam, her vitals are given: T: 98.6 F, HR: 115 bpm, BP: 95/53, RR: 14, SaO2: 97% on room air

venous insufficiency

73-year-old female with complaints of heavy, restless legs and nocturnal cramping of her calves. She has a past medical history of obesity, hypertension, and previous deep venous thromboses after periods of long travel. On physical exam, her bilateral lower legs are edematous with brown hyperpigmentation around the ankles. There are no ulcers. She is scheduled for a duplex ultrasound.

tricuspid regurgitation

73-year-old man with a history of rheumatic fever and coronary atherosclerosis presents to the emergency department with dyspnea on exertion and orthopnea. He called 911 because he could not catch his breath. On examination, he was found to have jugular venous distention (JVD), hepatic congestion, and peripheral edema. A blowing holosystolic murmur along the left sternal border that is intensified during a Valsalva maneuver and inspiration is noted. Atrial fibrillation is noted on his ECG

varicose veins

77-year-old Hispanic female with a dull ache in her legs that is worsened with prolonged standing and relieved with rest and elevation of her legs. She has 14 grown children and a past medical history of obesity and hypertension. On physical exam, her bilateral lower legs are edematous with multiple dilated, tortuous superficial veins.

venous thrombosis

78-year-old female complaining of generalized pain and edema in her left leg. She denies chest pain, shortness of breath, and hemoptysis. She takes 2.5 mg warfarin daily for atrial fibrillation and her INR is 2.6. On physical examination the patient experience calf pain with dorsiflexion of the left foot. The patient has a positive D-dimer and a lower extremity ultrasound reveals the presence of a deep venous thrombosis in the left popliteal vein.

coarctation of the aorta

8-year-old boy who is seen for the first time in your office. His parents report that he tires easily and often complains of weakness in his legs. Physical exam shows a healthy boy with a blood pressure of 141/91 mmHg. You notice that his lower extremities are slightly atrophic with a mottling appearance. Upon further examination, he is found to have very weak and delayed femoral pulses with a blood pressure of 96/60 in the lower extremities. He has a late systolic ejection murmur on cardiac auscultation. CXR is performed demonstrating a "figure of 3 sign"

cardiogenic shock

critically ill 69-year-old male with a history of coronary artery disease is hypotensive following a large anterior wall myocardial infarction. He is noticeably lethargic, somnolent and confused. He has very weak peripheral pulses, a rapid heart rate and his extremities are cool to the touch.

tricuspid stenosis

diastolic rumbling murmur heard best at the left lower sternal margin and the xiphoid, augmented during inspiration

atrial septal defect

healthy 7-year-old girl who has reached all developmental milestones. On examination, the precordium is hyperdynamic with a prominent right ventricular heave. A grade III/VI systolic ejection murmur is present in the 2nd left intercostal space (pulmonic position) with an early to mid-systolic rumble and fixed splitting of the second heart sound (s2) during inspiration and expiration.