A 75-year-old male presented with acute, severe right upper quadrant (RUQ) pain, radiating to the right shoulder and associated with nausea and vomiting. He denied any fever, chest pain, shortness of breath, change in bowel habits or similar episodes in the past. He had a history of coronary artery disease, well-controlled hypertension and biopsy-proven GCA, diagnosed 15 months ago. Physical examination: afebrile;pulses: 86/min, regular and symmetric; BP: 170/108 mm;tenderness in the RUQ with palpable gall bladder 4 cm below the right costal margin; an ejection systolic murmur in the aortic area. The rest of the physical examination was essentially unremarkable. Laboratory data: WBC-10000, Hb-13.8 and platelets-251,000. The CT scan of abdomen was suggestive of acute cholecystitis. A dissection of the superior mesenteric artery (SMA) was also noted. CXR showed aneurysm of ascending aorta. CT scan of thorax showed a Stanford Type A aortic dissection (AD) with aneursymal dilation of 7 cm. Communication of the true and false lumen suggested chronicity (see figure) . After stabilization of BP, he underwent an emergency laparoscopic cholecystectomy which led to a resolution of his abdominal pain. Subsequently, he was referred for an elective repair of his asymptomatic, chronic aortic dissection. IMPLICATIONS/DISCUSSION: Horton's syndrome or GCA is the commonest primary systemic vasculitis in the United States, associated with diverse manifestations and outcomes. The true incidence of aortic involvement is unknown, but is estimated to be 3±15 %. Patients with giant cell aortitis may be asymptomatic or may present with aortic arch syndrome, dilation of aorta, aortic aneurysm, AD or aortic incompetence. Although, in this patient AD may well be attributed to atherosclerosis,the history of GCA and segmental involvement of ascending aorta and SMA implicate GCA as a predisposing condition.A high incidence of thoracic aortic aneurysm has led Evans et al to recommend annual CXR, including lateral views in patients of GCA. Since the diagnosis of GCA is commonly made by the internists, awareness of it's possible complications helps us manage these patients better. A 37 year old Mandarin speaking woman with no known PMH presented with chest palpitations for 6 months. Her history was obtained in a crowded, noisy ER through a telephone translator, with her husband as a middle translator. She states having symptoms for over 6 months with acute decompensation over the last 2 months involving constant fast heart rate, swelling in her face, abdomen, and extremities for 2 months, dyspnea when walking 2±3 blocks, a 20 lb unintentional weight loss, poor concentration, and constipation. She went to a doctor 1 month ago and was told she has a thyroid problem, but has not been taking the prescribed medications. More than 10 years ago in China, she had problems with her thyroid and was given Western medications for 6 months with improvements. Otherwise, review of systems was unremarkable. On exam, her pulse was irregular, atrial fibrillation, at 125±145, BP 98/64. She was anicteric with swollen eyelids, no proptosis. She had an enlarged thyroid, JVD, a hyperdynamic precordium, no heart murmurs, a distended abdomen, and non-pitting edema in all extremities. Lab studies showed a mild transaminitis, negative hepatitis serologies, and positive thyroid stimulating antibodies. She was diagnosed with Graves disease. Echocardiography showed severe tricuspid regurgitation and right heart failure without evidence of left sided dysfunction, pulmonary artery hypertension or septal defects. Her atrial fibrillation was treated with beta blockers and anticoagulation, and she was scheduled for repeat echocardiogram in 2 months to evaluate for valve disease that may be contributing to her right sided failure. She would like more children, so she opted for medical therapy with propythiouracil to treat her hyperthyroidism and would consider radioactive iodide or surgical therapy after her thyroid disease is under control. IMPLICATIONS/DISCUSSION: 1. Obtaining a complete history in non-English speaking patients can be difficult. Despite seeing a private doctor, this patient came to the ER without her primary doctor's support, without her medications, and without the ability to communicate with hospital doctors. Studies have shown that intepreter services increase cost-effectiveness and quality of care as well as patient understanding and participation in healthcare, despite potential increases in the time and resources to provide such services. 2. Recurrent hyperthyroidism, most commonly due to Grave's disease, is treated similarly to the initial episode. Anti-thyroid medications are the drug of choice in pregnant women and are not known to effect reproductivity. Radioactive iodide is contraindicated in pregnancy, although has been shown to have no effect on reproductivity in the long term. Surgery is effective, although has no advantages and has been associated with increased fetal losses if done during pregnancies. A 74 year old male was brought by his friend to the emergency room with a four week history of gradually progressive shortness of breath that began 2±3 days after dual-chamber pacemaker placement for Mobitz II heart block and symptomatic bradycardia. The procedure was without any immediate complications. CXR post-precodure was negative for pneumothorax. He currently denied chest pain, cough, fevers, chills, sweats, lightheadedness, or dizziness. PMH was significant for, in addition to Mobitz II heart block, coronary artery disease, severe aortic stenosis and hypertension. Medications included felodipine 10 mg PO qd, simvastatin 10 mg PO qd, and lisinopril 20 mg PO qd. He had a remote history of tobacco use and was a former steel mill worker. On physical examination, VS: HR 105, RR 26, BP 150/90, pulse ox 92% (on room air). Pertinent findings included no JVD, a II/VI SEM at the right upper sternal border radiating to carotid arteries, laterally displaced PMI, decreased breath sounds on the left 2/3 up the lung fields, no organomegaly and 1+ pretibial edema. CXR showed a free flowing large left pleural effusion. The patient was admitted to the hospital and a thoracentesis was performed from which serosanguinous fluid was obtained. CT of the chest demonstrated a perforated right ventricle from the pacer wire. Surgical repair was successful but the patient had a very complicated postoperative course and expired. IMPLICATIONS/DISCUSSION: Pacemaker insertion is a relatively common and safe procedure and can be lifesaving. Ventricular rupture is a rare, albeit potentially serious, complication. The elderly, in whom most pacemakers are inserted, are at increased risk of complications. The Pacemaker Selection in the Elderly (PASE) study, a prospective multicenter trial involving 407 patients age 65 years and older, documented a 6.1% complication rate; 4.4% of patients required a repeat procedure. The most common complications were lead dislodgement (2.2%), pneumothorax (2.0%and observed only in those with subclavian venous access) and cardiac perforations (0.98%). Most perforations occur intraoperatively and rarely cause symptoms. However, as in our patient, serious complications, including death, have been reported postoperatively. Complications of pacemaker insertion may masquerade as other less serious entities with symptoms of dyspnea, chest pain, fever and weakness. It is paramount that internists be alert to the potential serious complications of cardiac rupture and pneumothorax in the patient presenting with these symptoms postprocedure. Symptomatic patients require surgical intervention. A 53 year-old Puerto Rican male presents with a chief complaint of two years of increasing dyspnea on exertion. Past medical history was notable for multiple episodes of pneumonia. Although the patient had been successfully treated as an outpatient during these episodes with oral antibiotics, his chronic baseline dyspnea and decreasing exercise tolerance continued to worsen. For one of these exacerbations, the patient was admitted to the hospital, where physical exam revealed nystagmus, poor visual acuity, oculocutaneous albinism, and a bleeding diathesis. Radiological studies revealed bilateral lower lobe infiltrates and diffuse pulmonary honeycombing fibrosis. The patient improved following a ten-day course of IV cefotaxime, gentamycin, and chest physical therapy. IMPLICATIONS/DISCUSSION: The combination of oculocutaneous albinism, a bleeding diathesis, and pulmonary fibrosis in this Puerto Rican patient raised the suspicion for Hermansky-Pudlak Syndrome. HPS is an inherited disease which results in a platelet storage pool defect and lysosomal accumulation of a substance called ceroid lipfuscin. HPS is an autosomal recessive syndrome found primarily in individuals from the northwestern quadrant of Puerto Rico. Patients have legal blindness, nystagmus, iris transillumination, foveal hypoplasia, decreased number of melanocytes, pulmonary fibrosis, renal disease and granulomatous enteropathic disease. Lab studies in patients with HPS may show an increased bleeding time with a therapeutic response to desmopressin, decreased bone density, and genetic testing showing a mutation on the HPS1 gene on chromosome 10q23. The most accurate diagnosis, however, is made by a pathognomic platelet morphology diagnosed only by electron microscopy. Management consists of recognizing the disease, having a lower threshold for admitting individuals for inpatient management, and administration of immunosuppressants and steroids. Current trials of a test drug called pirfenidone are being conducted and offer patients some hope for a treatment. Back to our patient: A careful history taking revealed that the patient presented above had all of the above manifestations, even decades prior to his official diagnosis being made. Management of this patient's disease ultimately consisted of various trials of steroids, interferon, and methotrexate. While the inpatient stay focused primarily on his pulmonary pathology, outpatient management consisted of patient education to minimize complications of the disease and carefully orchestrated care with numerous specialists. week history of progressive pain and swelling in his left index finger after an attempt to straighten an iron pipe with this left hand. Past medical history was significant for a similar episode involving his right index finger after trauma that resolved with symptomatic treatment. Patient had a 50pack year history of smoking. The rest of his review of systems was unremarkable. Physical examination was unremarkable except for a swollen and tender left index finger with a gangrenous tip. The left ulnar pulse was absent. His radial pulses were intact in both extremities. Laboratory data including ANA and sedimentation rate were within normal limits. An arteriogram of the left upper extremity revealed thrombosis of the distal ulnar artery and occlusion of digital arteries of the second digit that were thought to be secondary to embolic events from the ulnar artery thrombus. Duplex ultrasound also revealed a thrombosed pseudoaneurysm in the left ulnar artery at the hypothenar eminence. Diagnosis of Hypothenar Hammer Syndrome (HHS) was made. IMPLICATIONS/DISCUSSION: HHS is a rare clinical entity that results from repetitive palmar trauma leading to damage of the ulnar artery as it passes over the hammate bone. The syndrome usually manifests as unilateral digital ischemia caused by embolic digital artery occlusion from the thrombosed palmar ulnar artery. It is predominantly seen in males around the age of 40. In a small study of 21 patients, 12 out of 13 who had arteriography of both upper extremities had bilateral palmar ulnar disease (1). Diagnosis is made on clinical features and confirmed by angiography that shows a palmar ulnar artery abnormality and digital artery occlusion. Treatment may include surgery involving excision of abnormal palmar ulnar artery segment. LEARNING OBJECTIVES: To recognize and manage pustular psoriasis and to differentiate it from other causes of erythroderma. CASE INFORMATION: DP is a 58-year-old African American male who presented with an exfoliative erythroderma and pustules in the palmar-plantar areas that had coalesced to form`l akes of pus.'' The patient noted a similar but milder eruption 3 months earlier in which he was treated at another facility with oral prednisone with some improvement. He reported that the pustules had started on his hands, progressing rapidly over several days to affect the entire body. Erosions later appeared in the mouth. He complained of an intense pruritus and burning sensation along with a fetid odor. At the time of presentation he was noted to be febrile with a leukocytosis. A skin biopsy showed spongiform pustules in the upper epidermis with numerous PMNs present. Inpatient management included a combination of actretin, IV vancomycin, and topical mid-potency steroids, with rapid improvement in the patient's condition. IMPLICATIONS/DISCUSSION: A presentation of erythroderma should prompt the physician to consider pustular psoriasis, pemphigus foliaceus, pityriasis rubra pilaris, underlying leukemia/lymphoma, severe atopic dermatitis, ichthyoses, drug induced erythroderma, diffuse seborrheic dermatitis, scabies, and staphylococcal scalded skin. Pustular psoriasis can be differentiated by sudden onset of acral pustular lesions, fever, intense pruritis, and occasionally, hypocalcemia and mucous membrane lesions. Patients will often have a personal or family history of plaque psoriasis and/or psoriatic arthritis. Treatment of choice is acitretin (a second generation retinoid). Topical steroids are often helpful, but systemic steroids should be avoided.