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A 65-year-old woman with a history of HIV infection, hypertension, and hyperlipidemia had a 1-week history of cough with pink sputum and mild shortness of breath on exertion, but no fever, chills, night sweats, rhinorrhea, or nasal congestion.

A 58-year-old woman presented with an 8-month history of shortness of breath on exertion. Previous chest imaging had shown pleural thickening and peripheral nodules in the upper lung zones, without lymphadenopathy. A diagnostic procedure was performed.

A 38-year-old woman was admitted to this hospital because of fatigue, malaise, and lightheadedness, with dyspnea on exertion, bruising, dark urine, and headache. Laboratory tests revealed anemia and thrombocytopenia. Diagnostic tests were performed.

A 78-year-old man presented with a 4-month history of worsening fatigue, weakness, and anorexia, with an unintentional weight loss of 11.4 kg. He reported fevers, chills, night sweats, dry mouth, nonproductive cough, dyspnea with minimal exertion, nausea, and postural light-headedness.

A 73-year-old man presented with a history of progressive, symmetric edema that began in the lower extremities and extended to involve his thighs, scrotum, and arms. He had dyspnea on exertion, orthopnea, and paroxysmal nocturnal dyspnea, as well as chest pressure on mild exertion.

Background Testosterone supplementation has been shown to increase muscle mass and strength in healthy older men. The safety and efficacy of testosterone treatment in older men who have limitations in mobility have not been studied. Methods Community-dwelling men, 65 years of age or older, with limitations in mobility and a total serum testosterone level of 100 to 350 ng per deciliter (3.5 to 12.1 nmol per liter) or a free serum testosterone level of less than 50 pg per milliliter (173 pmol per liter) were randomly assigned to receive placebo gel or testosterone gel, to be applied daily for 6 months. Adverse events were categorized with the use of the Medical Dictionary for Regulatory Activities classification. The data and safety monitoring board recommended that the trial be discontinued early because there was a significantly higher rate of adverse cardiovascular events in the testosterone group than in the placebo group. Results A total of 209 men (mean age, 74 years) were enrolled at the time the trial was terminated. At baseline, there was a high prevalence of hypertension, diabetes, hyperlipidemia, and obesity among the participants. During the course of the study, the testosterone group had higher rates of cardiac, respiratory, and dermatologic events than did the placebo group. A total of 23 subjects in the testosterone group, as compared with 5 in the placebo group, had cardiovascular-related adverse events. The relative risk of a cardiovascular-related adverse event remained constant throughout the 6-month treatment period. As compared with the placebo group, the testosterone group had significantly greater improvements in leg-press and chest-press strength and in stair climbing while carrying a load. Conclusions In this population of older men with limitations in mobility and a high prevalence of chronic disease, the application of a testosterone gel was associated with an increased risk of cardiovascular adverse events. The small size of the trial and the unique population prevent broader inferences from being made about the safety of testosterone therapy. (ClinicalTrials.gov number, NCT00240981.)

A 23-year-old man was transferred to this hospital because of cough, hoarseness, fever, and abnormalities on chest imaging. One month before admission, a nonproductive cough developed, followed by hoarseness, dyspnea on exertion, and fever. Imaging studies at another facility showed pulmonary and mediastinal masses and a lesion in the pelvis. Positron-emission tomographic scans obtained at this hospital showed 18F-fluorodeoxyglucose–avid lesions. A diagnostic procedure was performed.

A 63-year-old woman was admitted to the hospital because of a 3-week history of dyspnea on exertion, associated left subscapular burning pain, and a mild dry cough. She had a history of ulcerative colitis, which was most recently treated with azathioprine and infliximab. On examination, there were inspiratory wheezes and rales, without expiratory wheezes. Chest imaging showed ground-glass opacities in both lower lobes. A diagnostic procedure was performed.

A 57-year-old man presented to the emergency department with a 2-week history of progressive dyspnea on exertion, edema of the legs, a nonproductive cough, and scant hemoptysis. He also reported occasional passage of bright red blood from his rectum and intermittent nausea and vomiting during the previous 4 days.

A 10-year-old girl was seen because of dyspnea and noisy respirations. Three weeks earlier, sharp pain in the chest and shortness of breath had developed abruptly, followed by dyspnea and noisy respirations with exertion. Symptoms did not improve with the use of bronchodilators. A diagnostic procedure was performed.

A 47-year-old man reports a six-month history of intermittent chest discomfort while playing squash. He describes lower substernal tightness with numbness of the left upper arm only during exertion. He does not smoke. His father died suddenly at the age of 49 years. His blood pressure is 138/84 mm Hg. The level of total cholesterol is 261 mg per deciliter, low-density lipoprotein cholesterol 172 mg per deciliter, and high-density lipoprotein cholesterol 50 mg per deciliter, and the triglyceride level is 113 mg per deciliter. An exercise test is positive, with pain and 1.5 mm of horizontal ST-segment depression at stage 4 of the Bruce protocol. How should the patient's case be managed?

A 68-year-old man originally from the Philippines presented with a three-month history of increasing dyspnea on exertion and orthopnea. He also reported an unintentional weight loss of 7 kg (15 lb), night sweats, and abdominal bloating.

A 28-year-old man presents with a two-year history of increasing dyspnea on strenuous exertion and is found to have hypertrophic cardiomyopathy, with a septal thickness of23 mm and a left ventricular outflow gradient of 80 mm Hg. There is no family history of hypertrophic cardiomyopathy or sudden death. Forty-eight-hour Holter monitoring shows infrequent premature ventricular contractions. How should this patient be treated?

Presentation of Case A 42-year-old woman was admitted to another hospital because of worsening dyspnea and cough. During the year before admission, the patient had had mild dyspnea on exertion, a cough that was occasionally productive of whitish mucus, slight fatigue, and a weight loss of 7 kg. Three weeks before admission, the dyspnea and cough suddenly worsened and were accompanied by fever. Use of a codeine–guaifenesin cough syrup was ineffective. The patient came to the emergency room. The patient worked at a sedentary occupation, without known exposure to industrial dusts. She had smoked one and a half packs of . . .

Presentation of Case A 26-year-old man was admitted to the hospital because of a mass in the knee. The patient had been in good health except for a nine-year history of intermittent pain in the right knee. At first the pain occurred only after exertion, especially when he was playing soccer, and then resolved spontaneously. The pain subsequently became more frequent and more intense. Three years before admission, the pain became continuous, although it was less severe after the patient stopped participating in sports. One year before admission, he began to have intense pain in the medial part of the . . .

Stage A 65-year-old woman was referred to a cardiologist for the evaluation of progressive chest pain. Placement of an aortobifemoral conduit had been performed 14 years earlier for occlusive aortoiliac disease. She had smoked two packs of cigarettes a day for over 40 years. Her history of chest pain was typical of crescendo angina pectoris on exertion, without symptoms that were prolonged or that occurred at rest. Two years earlier, she had had a transient ischemic attack consisting of facial droop and aphasia. She had bilateral carotid bruits, which were greater on the left side than on the right, and . . .

Among the approximately 1.1 million firefighters in the United States (of whom about 70% are volunteers and 30% are paid career personnel), about 100 die each year in the line of duty.1 With the exception of 2001, when 344 firefighters died as a result of the events of September 11 at the World Trade Center in New York City, the number of deaths per year has stayed relatively steady, even though the number of structural fires in the United States has been steadily decreasing. Nearly half of the deaths that occur while firefighters are on duty are related to cardiovascular . . .

Presentation of Case A 46-year-old man was admitted to the hospital because of unstable angina pectoris. The patient had been well until three weeks earlier, when he began to have episodes of anterior and posterior chest pain that radiated to the right arm. They occurred only on exertion, were relieved by rest, and lasted for a few minutes to over a half hour. During the several days before admission, the chest pain increased in frequency and severity. On the day before admission, the patient entered another hospital, where no evidence of acute myocardial infarction was found. Cardiac catheterization revealed that . . .

Stage A 60-year-old man came to the hospital because of intermittent wheezing, progressive dyspnea on exertion, and severe orthopnea, which had been present for several weeks. The patient had also had occasional vague chest pressure that was not clearly brought on by exertion. In the emergency room, the patient was short of breath while breathing room air; his oxygen saturation was 84 percent. On physical examination his blood pressure was 192/78 mm Hg. He had bibasilar rales, a gallop rhythm, and a right carotid bruit. The electrocardiogram showed no abnormalities, and the chest film demonstrated a normal heart size with . . .

Heart failure is a complex of symptoms — fatigue, shortness of breath, and congestion — that are related to the inadequate perfusion of tissue during exertion and often to the retention of fluid. Its primary cause is an impairment of the heart's ability to fill or empty the left ventricle properly. The management of heart failure can no longer be confined to the relief of symptoms. The processes that contribute to left ventricular dysfunction may progress independently from the development of symptoms (Figure 1). Treatment to prevent or delay the progression of left ventricular dysfunction may therefore be quite different . . .

A 76-year-old man with a 1-week history of continuous chest pain presented to the ED with rapidly progressive dyspnea on exertion. Transthoracic echocardiography revealed a large, sharply demarcated interventricular septal defect with a turbulent left-to-right transseptal flow, shown in videos.

Background It is controversial whether the onset of myocardial infarction occurs randomly or is precipitated by identifiable stimuli. Previous studies have suggested a higher risk of cardiac events in association with exertion. Methods Consecutive patients with acute myocardial infarction were identified by recording all admissions to our hospital in Berlin and by monitoring a general population of 330,000 residents in Augsburg, Germany. Information on the circumstances of each infarction was obtained by means of standardized interviews. The data analysis included a comparison of patients with matched controls and a case-crossover comparison (one in which each patient serves as his or her own control) of the patient's usual frequency of exertion with the last episode of exertion before the onset of myocardial infarction. Results From January 1989 through December 1991, 1194 patients (74 percent of whom were men; mean age [±SD], 61 ±9 years) completed the interview 13 ±6 days after infarction. We found tha...

Background Despite anecdotal evidence suggesting that heavy physical exertion can trigger the onset of acute myocardial infarction, there have been no controlled studies of the risk of myocardial infarction during and after heavy exertion, the length of time between heavy exertion and the onset of symptoms (induction time), and whether the risk can be modified by regular physical exertion. To address these questions, we collected data from patients with confirmed myocardial infarction on their activities one hour before the onset of myocardial infarction and during control periods. Methods Interviews with 1228 patients conducted an average of four days after myocardial infarction provided data on their usual annual frequency of physical activity and the time, type, and intensity of physical exertion in the 26 hours before the onset of myocardial infarction. We compared the observed frequency of heavy exertion (6 or more metabolic equivalents) with the expected values using two types of self-matched analys...

Presentation of Case A 71-year-old woman was admitted to the hospital with biventricular congestive heart failure and a pericardial effusion. The patient was well and active until four months earlier, when she began to have epigastric "pressure" on exertion, sometimes accompanied by dyspnea and relieved by one minute of rest. About the same time she also noticed the onset of an intermittent petechial rash that tended to occur at points of contact or friction with her clothing. Two months before entry a prolonged episode of epigastric pressure and dyspnea occurred, and she was admitted to another hospital. An electrocardiogram showed . . .

Presentation of Case A 76-year-old man was admitted to the hospital because of coronary artery disease and staphylococcal sepsis. The patient was well until four years earlier, when he consulted a physician because of "burning" anterior chest pain on exertion. Physical examination showed a Grade 3 systolic ejection murmur and a Grade 1 aortic diastolic murmur. An electrocardiogram revealed atrial fibrillation, with complete right-bundle-branch block and left anterior hemiblock. A Doppler ultrasonographic examination disclosed evidence of aortic stenosis, with an aortic-valve pressure gradient of 75 mm Hg. The patient was referred to this hospital, where cardiac catheterization showed that the . . .

Three well-conditioned men who ran the 2011 Boston Marathon had acute coronary thrombosis shortly after completing the marathon. The authors discuss possible explanations for the occurrence of coronary thrombosis after prolonged exertion.

A 55-year-old woman with a remote history of Hodgkin's lymphoma was admitted with subacute, progressive dyspnea on exertion. Distention of the jugular veins and elevation of jugular venous pressure during inspiration were observed and are shown in a video.

A 58-year-old obese woman with rheumatic heart disease presented with progressively increasing dyspnea on exertion for the past month. Transesophageal echocardiography revealed a mass, freely floating within the left atrial cavity, shown in a video.

This interactive feature presents the case of a 65-year-old woman with a 1-week history of fatigue, dyspnea on exertion, daily fevers, and night sweats. Test your diagnostic and therapeutic skills at NEJM.org.

To the Editor: Although the addition of a long-acting β2-agonist such as salmeterol to an inhaled corticosteroid has been demonstrated to provide greater control of asthma than does a substantially increased dose of the inhaled corticosteroid,1 this medication was associated with an increased risk of asthma-related death in a large population study.2 We have identified two adolescent boys with poorly controlled asthma and a history consistent with sudden asphyxial episodes during modest exertion while receiving inhaled corticosteroids and salmeterol. In addition to reporting an inadequate response to their rescue inhaler when symptomatic, they had no apparent bronchoprotective effect . . .

The spectrum of acute mountain sickness ranges from mild, nonspecific symptoms to high-altitude pulmonary edema and high-altitude cerebral edema. Most deaths from high-altitude illness occur with high-altitude pulmonary edema, the risk of which is related to the rate of ascent, individual susceptibility, and the level of exertion. Cold ambient temperature constitutes an additional risk factor. High-altitude pulmonary edema occurs worldwide, with the incidence peaking in the winter months because of ski tourism. Mountain climbers and skiers who have had an episode of high-altitude pulmonary edema are susceptible to unpredictable recurrence when they are again exposed to high altitudes. The condition . . .

A 57-year-old woman presented with a 4-month history of leg swelling and dyspnea on exertion. Physical examination revealed a grade 3/6 holosystolic murmur at the right upper sternal border and an early diastolic decrescendo murmur at the left lower sternal border.

To the Editor: The acute coronary syndromes — myocardial infarction, unstable angina, and sudden cardiac death — have been shown to be triggered by heavy physical exertion, including snow shoveling...

A 58-year-old woman with a 20-year history of goiter presented with a two-month history of progressive dyspnea on exertion, occasional stridor, and a choking sensation while supine. She had previously been asymptomatic. Physical examination revealed a diffusely enlarged thyroid with no palpable nodules (Panel A), but the lower poles of the thyroid were not palpable. Within 30 seconds after she raised both arms simultaneously (Pemberton's maneuver), marked facial plethora (Pemberton's sign) developed, indicating compression of the jugular veins (Panel B). The patient's serum thyrotropin and free thyroxine concentrations were normal. Computed tomography of the neck revealed a large goiter extending . . .

At one time or another, most physicians have encountered a patient -- perhaps even a friend or family member -- who suffered a heart attack during strenuous physical exertion. Some familiar example...

Figure 1. An obese 82-year-old woman with a history of hypertension and type 2 diabetes mellitus had had dyspnea on exertion and swelling of her legs for three to four months. Transthoracic echocardiography revealed a right atrial mass with extension into the inferior vena cava. Computed tomography of the chest and abdomen showed that the mass originated in the left kidney. The results of coronary angiography, ventilation–perfusion scanning, and bone scanning were normal. A radical left nephrectomy and excision of the right atrial mass were performed with the use of cardiopulmonary bypass. Intraoperative two-dimensional transesophageal echocardiography with an omniplane probe . . .

Figure 1. A previously healthy 35-year-old man had increasing dyspnea on exertion over a period of several months. The results of a physical examination and transthoracic echocardiography suggested that he had pulmonary arterial hypertension and severe tricuspid regurgitation. A contrast-enhanced helical computed tomographic (CT) scan of the chest was obtained to look for evidence of pulmonary thromboembolism and to assess the lung parenchyma. Contiguous axial CT images through the main pulmonary arteries (Panel A) showed eccentric endothelialized thrombi in both pulmonary arteries (arrows). A CT image obtained at the level of the aortic arch (Panel B) showed a disparity in . . .

Presentation of Case A 73-year-old woman was admitted to the hospital because of unstable angina pectoris. She was well until about 10 years earlier, when hypertension was found. Five years before admission there was the onset of chronic stable angina pectoris, which responded to nitroglycerin. During the year or two before entry angina became more frequent and occurred on minimal exertion, including washing dishes; she was occasionally awakened from sleep by chest pain. Sweating and dyspnea frequently accompanied the anginal episodes. During the 15 months before admission she was admitted on five occasions to another hospital because of prolonged anginal . . .

We have assessed the long-term results of coronary bypass surgery performed for unstable angina in 1282 patients from 1970 to 1982. The operative mortality was 1.8 per cent; in the first 4 years it was 2.5 per cent, and in the last 8 1/2 years it was 1.7 per cent. Using actuarial techniques, we determined that the 5-year and 10-year survival rates (mean +/- S.E.) were 92 +/- 1 per cent and 83 +/- 2 per cent, respectively, for the whole group. For patients with "normal" left ventricular function, they were 92 +/- 2 per cent and 86 +/- 3 per cent, and for patients with "abnormal" left ventricular function 91 +/- 2 per cent and 79 +/- 4 per cent (P = 0.14). No significant differences were observed in the long-term survival for any of the three clinical subgroups of patients with unstable angina--angina at rest, angina after recovery from acute myocardial infarction, and progressive angina of recent onset (P = 0.49). The reoperation rates at 5 and 10 years were 6 +/- per cent and 17 +/- 3 per cent. Currently, 61 per cent of the survivors have no angina; angina occurs on severe exertion in 20 per cent, on ordinary exertion in 14 per cent, and on mild exertion in 5 per cent. We conclude that coronary bypass surgery is an effective form of therapy (for up to 10 years) in patients with unstable angina.

Presentation of Case A 22-year-old graduate student was admitted to the hospital because of a pericardial effusion. He was well until three months previously, when, during a visit to his home in southern California, he became fatigued, with a low-grade fever. Six weeks later a nonproductive cough developed, accompanied by wheezing on exertion and frequent headaches. During the next three weeks he had pain in the chest and both shoulders after ingesting small amounts of alcohol. Three weeks before admission night sweats and exertional dyspnea appeared, and the wheezing worsened. Two weeks before admission he entered the university infirmary, where . . .

Some patients with chronic airflow obstruction experience dyspnea with mild arm exercise but not with more-intense leg exercise. To investigate why these patients have limited endurance during arm exertion, we studied ventilatory responses to exercise with unsupported arms in 12 patients with chronic airflow obstruction (mean [+/- SD] forced expiratory volume in one second, 0.68 +/- 0.28 liters). Unloaded leg cycling was also studied for comparison. In the five patients who had the most severe airflow obstruction, arm exercise was limited by dyspnea after 3.3 +/- 0.7 minutes, and dyssynchronous thoracoabdominal breathing developed. In the other seven patients, arm exercise was limited by the sensation of muscle fatigue after 6.1 +/- 2.0 minutes (P less than 0.05), and dyssynchronous breathing did not occur. None of the 12 patients had dyssynchronous breathing during unloaded leg cycling. Maximal transdiaphragmatic pressure, a measure of diaphragmatic fatigue, declined similarly after arm and leg exercise in both groups. During unsupported arm work, the accessory muscles of inspiration help position the torso and arms. We hypothesize that the extra demand placed on these muscles during arm exertion leads to early fatigue, an increased load on the diaphragm, and dyssynchronous thoracoabdominal inspirations. This sequence may contribute to dyspnea and limited endurance during upper-extremity exercise.

Presentation of Case A 60-year-old man was admitted to the hospital because of an intracardiac mass. There was a questionable history of a coronary attack 15 years earlier, characterized by "crushing" chest pain, for which he was treated in another hospital for one month. The patient recovered but experienced bouts of exertional chest pain that usually radiated to the left arm and episodes of exertional dyspnea and palpitations. Thirteen months before entry the exertional dyspnea worsened, and chest pain on exertion and palpitations became more frequent. He was admitted repeatedly to a second hospital because of recurrent chest pain, with . . .

We sought to elucidate further the neurologic defect of idiopathic orthostatic hypotension, which appears to represent two distinct clinical entities. While recumbent, patients with multiple central-nervous-system defects, as well as peripheral autonomic nervous dysfunction, have normal plasma levels of norepinephrine that fail to increase normally after standing or exertion (P less than 0.001 by t-test as compared to controls). While recumbent, patients with peripheral autonomic insufficiency without signs of central-nervous-system defects have low levels of plasma norepinephrine (P less than 0.001) that also fail to increase normally after standing or exercising (P less than 0.001). Both groups have low levels of plasma dopamine-beta-hydroxylase (P less than 0.02). These findings are consistent with other pathological and pharmacologic observations suggesting that patients with central-nervous-system disease are unable to activate appropriately an otherwise intact sympathetic nervous system, whereas in patients without signs of central-nervous-system disease the deficit affects peripheral sympathetic nerves.

Presentation of Case A 37-year-old man was admitted to the hospital because of increasing dyspnea and edema. A diagnosis of congenital heart disease was made at the age of six months, when a physician found mild cyanosis and a loud systolic murmur. Frequent respiratory tract infections occurred during infancy. He began to crawl at nine months and to walk at two years. He was often observed in a knee—chest position in his crib, and he squatted after exertion during his early years. An uncomplicated tonsillectomy was performed at three years of age. At the age of six years a surgical . . .

Presentation of Case A 35-year-old woman was admitted to the hospital because of chest pain. She was well until 14 years previously, when she began to experience wheezing on exertion. Aminophylline was prescribed, with improvement. Four years before admission the wheezing increased, with weakness, weight loss, nocturnal sweats, and rise of the temperature to 38.1°C. A cough productive of yellow sputum developed, and mild anterior chest pain and dyspnea occurred. She was admitted to this hospital. X-ray films of the chest (Fig. 1) showed patchy infiltrates in both upper lobes; an azygos lobe was present; the heart was not enlarged. . . .

Presentation of Case A 64-year-old man was admitted to the hospital because of pulmonary hypertension. The patient was a former fire chief, who had enjoyed excellent health and an athletic life style until five years earlier, when fatigue and dyspnea on exertion developed gradually, and he discontinued playing singles tennis. At the same time he began to experience occasional bouts of aching pain to the right of the sternum on climbing stairs. Several months later he fainted after fighting a fire. Four years before entry a stress test was begun but was halted because of the occurrence of numerous premature . . .

Presentation of Case A 55-year-old man was admitted to the hospital because of intermittent claudication of the arms. He was well until five years earlier, when a diagnosis of diabetes mellitus was made. Dieting resulted in a weight reduction from 90 to 68.2 kg. On a routine annual physical examination 10 weeks before admission the radial and brachial pulses were found to be diminished bilaterally. One month before entry he began to have weakness and pain in both hands and forearms on minor exertion such as tying his necktie, shaving, or completing a single-page government form, with recovery after several . . .

Presentation of Case A 73-year-old woman was admitted to the hospital because of dehydration. For several years she had been treated with prednisone and chlorambucil because of chronic lymphocytic leukemia. During the six months before entry she experienced severe dysphagia with substernal burning, which was unrelated to exertion, was imperfectly relieved by antacids and largely prevented the ingestion of solid foods. She lost 11 kg in weight. Four months before admission she was treated for a febrile illness believed to be due to urinary-tract infection and cholecystitis, and mild dysuria persisted thereafter. Six weeks before entry, after a fall, peripheral . . .

Presentation of Case First admission. A seventy-three-year-old woman was admitted to the hospital because of dyspnea and weakness. The patient had had the gradual onset of dyspnea on exertion and p...