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Review of systems is significant for frequent migraine headaches, worsening shortness-of-breath, dyspnea-on-exertion, and orthopnea.
Family History: Four out of six siblings have recurrent epistaxis and similar, albeit milder, skin findings than the patient. One sister died of "breathing-related problems"
Physical Examination: There were imultiple 1-3 mm nonblanchable violaceous papules on the face (Fig 1), lips (Fig 2), tongue, oral mucosa, back and arms. Telangectasias were present in the same distribution, some in assocation with the papules. The palms showed purple papules coalescing to plaques (Fig 3). Similar changes are noted on the soles. The chest, abdomen, and legs were relatively spared. Serum crust is adherent to the nasal mucosa.
Hemoglobin: 9; Hematocrit: 28
Chest X-Ray: Multiple pulmonary nodules
Stool: Brown, guaiac positive
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