Abdomen, Pelvis, and Perineun

A 60-year-old man presents with angina. He has no past medical history of heart disease. On questioning, the patient reveals that he had repeated sexually transmitted diseases in the past, including a painless chancre (a hard, round sore) on his penis, for which he never sought medical attention. RPR, VDRL slide test, and fluorescent treponemal antibody serologic tests (indicative of syphilis infection) are positive. Echocardiography and computed tomography of the heart are performed. The history of untreated syphilis suggests that these tests will most likely detect which of the following abnormalities?

A. Aortic valvular insufficiency and linear calcification along the ascending aorta
B. Bicuspid aortic valve with aortic stenosis
C. Large valvular vegetations from bacterial endocarditis
D. Right-sided heart failure from the carcinoid syndrome
E. Small fibrin deposits on the mitral valve from nonbacterial thrombotic (marantic) endocarditis

The answer is A. This is a case of syphilitic (luetic) aortitis. In syphilitic aortitis, the elastica of the aorta undergoes calcification and is replaced by fibrous tissue, resulting in dilation of the ascending aorta and separation of the aortic valve commissures, with resultant aortic insufficiency. Thus, echocardiography and computed tomography of the heart reveal calcification in a linear pattern along the ascending aorta, calcification in the coronary arteries (leading to anginal symptoms), and aortic valvular insufficiency.
Many of the drugs are expensive and therefore unavailable to poor segments of all societies. Another problem is detection. Hypertension is undetected in ≈31.6% of the population of the United States, according to the sixth report of the Joint National Committee.1 Of those in whom hypertension has been detected, 53.6% receive treatment. The problem is further compounded because it is estimated that only 27.4% of those hypertensive patients who receive treatment fully comply with their treatment and have their hypertension controlled.1 Clearly, there is a need for rethinking our approach to the treatment of hypertension. Detection could be increased by education. Nonpharmacologic treatment—such as exercise, weight loss, and low-salt diets—could provide inexpensive treatment, but it has proven very difficult to achieve compliance for these approaches. For treating hypertension on a worldwide scale, we need something akin to an immunization against hypertension. Because hypertension is polygenic and not a single-gene disease, except in very few cases,2 it cannot be immunized against.

Question2

Chest Pain