SVM Interactive Cases

A 66-year-old male presented to the Emergency Department (ED) with right upper quadrant pain and intermittent cough for two weeks. His medical history was significant for antiphospholipid antibody syndrome (APS), cephalic vein thrombophlebitis, pulmonary embolism, superior vena cava syndrome treated with chronic Coumadin, and mesenteric ischemia treated with bowel resection.

A 34-year-old woman presented with chronic left pelvic and flank pain since her teenage years. The discomfort was exacerbated by exercise and activity, and worsened after two pregnancies. She reported no edema. Her medical history included enlarging uterine fibroids and depression. It was negative for known renal or heart disease, or hypertension. She had no personal or family history of venous thromboembolism. Her workup was notable only for Factor V Leiden heterozygosity. Complete blood count, liver panel, and autoimmune profile were negative. Cardiac echo was normal.

A 49-year-old woman presented with a one-day history of left calf and thigh swelling. Four days earlier she underwent uncomplicated right knee arthroscopy under general anesthesia. She was immobile for 6 hours after the procedure but ambulated thereafter. Her left leg was tender. She complained of dyspnea on exertion. She denied cough or fevers. Her medical history was notable for pseudoxanthoma elasticum (PXE) diagnosed fifteen years earlier. At that time she presented with intermittent claudication affecting both calves. She suffered subretinal hemorrhages of the left eye that left her with markedly decreased visual acuity. She was taking oral contraceptives.

A 48-year-old woman presented complaining of a 10-day history of right arm pain and swelling. Her symptoms began after moving furniture from her office to a new location on another floor. She underwent a screening mammogram 12 days earlier, which was negative for malignancy. Her medical history was notable for well-controlled hypertension and tobacco abuse.

A 27-year-old previously healthy male presented with a 2-month history of persistent, unexplained pain and swelling within his right calf. His signs and symptoms worsened with exercise and only partially improved with elevation. An examination was remarkable for a swollen, mildly tender right calf measuring 3 cm larger in diameter than the left calf. An extensive evaluation prior to his presentation was unrevealing. A diagnostic procedure was performed (see Images 1 and 2).

A 54-year-old man presented with headache, nausea, vomiting, and dyspnea. His medical history included diabetes mellitus, hypertension, dyslipidemia, and a stroke with residual left-sided weakness. Several years ago, he suffered a right above-knee and left below-knee amputations after being struck by a train. Physical examination revealed an ill-appearing individual. The heart rate was 75 beats/minute and the blood pressure was 120/70. The heart rate was regular without murmur, lungs were clear, and abdomen benign. Laboratory evaluation revealed a white blood count of 24.0/mcL, serum creatinine 2.2 mg/dL, creatinine kinase 748 U/L with MB fraction 148, and troponin 16.7 µg/L. The EKG showed non-specific ST and T wave abnormalities. Coronary angiography performed via the right common femoral artery showed three-vessel coronary artery disease. The ejection fraction by echocardiography was 20%. The patient was slated for coronary artery bypass grafting the following day.

A 49-year old man with history of untreated hypertension for 15 years developed acute onset of right lower extremity pain and weakness. Physical examination revealed a severely hypertensive patient with systolic blood pressure of 240 mmHg in both upper extremities and absence of the right femoral pulse. An acute aortic dissection was suspected.

A 55-year old woman is seen in vascular clinic complaining of a two-month history of intermittent numbness and weakness of her left arm and hand. Her medical history is significant for right hip fracture. She has a remote history of tobacco use. Physical examination reveals an alert individual who appears healthy. Her heart rate was 70 bpm, blood pressure in right arm 90 mmHg and in the left arm 75 mmHg. The right carotid pulse is diminished. No bruit is present. Heart is regular with a I/VI systolic ejection murmur, lungs are clear, abdomen is benign. Pedal pulses are readily palpable. Laboratory evaluation revealed a white blood count of 10.9/mcL, ESR of 4 mm/hr, and CRP 0.6 mg/L. A magnetic resonance angiogram (MRA) was obtained (See Fig. 1). The wall of the thoracic aorta measured 5 mm thick.