A patient to another institutions ER department who presented with:
- Chest Pain
The patient had gone to a care centre earlier in the day, and on arriving there, the patient fell to the floor which was witnessed by her carer.
The patient had not lost consciousness but complained of severe chest pain followed by three episodes of vomiting.
The patient was then brought by ambulance to the ER department.
The patient suffered from dementia and was only able to say that there was chest pain. Sometime later, the patient said that there was also upper back pain.
There was no description from the admitting doctor of the quality of the pain or radiation.
The vomitus was of food only and contained no blood.
The previous medical history included dementia and untreated hypertension.
No other history was known.
On initial examination by the ER staff, the patient was afebrile, pulse 90 beats per minute, blood pressure 190/110, respiratory rate 18 per minute with oxygen sats of 90%.
Blood pressure in both arms was said to be the same.
Chest examination revealed bilateral crackles only with normal heart sounds.
Abdominal examination was said to be normal except for some epigastralgia but the chest pain at that time had resolved.
From history and examination differential diagnoses were formulated and included:
- Dissecting aortic aneurysm
- Acute myocardial infarction
- Unstable angina
- Acute perforation of an abdominal viscus
- Biliary colic
- Oesophageal spasm
The ECG showed an old inferior myocardial infarction but nothing acute. The chest Xray was abnormal with evidence of possible tracheal shift to the right and a right paratracheal mass. The right basal lung appeared to be collapsed and there was an effusion at the left base.
This was an unexpected finding from the history as there was no apparent serious illness with this patient in the past.
The patient appeared confused but in obvious pain from the wincing of the face but pain was denied on several occasions.
Hands were cold and the radial pulse was felt to mildly collapse. There was still a wide pulse pressure in the blood pressure despite intravenous anti-hypertensive therapy in the ER. Quinke Sign, Corrigan Sign and DeMusset Sign of aortic regurgitation were negative.
JVP was not raised. Frank sign of the earlobe was positive suggesting some coronary artery disease.
Trachea was depressed (tracheal tug) and mildly deviated to the right. There were no cervical lymph nodes present.
Heart examination revealed a very subtle murmur of aortic regurgitation with the occasional Austin Flint murmur that was no present on every cardiac cycle.
Lung examination revealed dullness at both bases with right basal crackles. On pressing the sternum, this reproduced some central chest pain but it was uncertain whether this was the same as the presenting chest pain as the patient could not describe the problem.
Abdominal examination revealed no AAA but on auscaultation there was a left renal bruit.
Pulses were equal in the upper limbs and femoral areas. The left dorsalis pedis was weaker than the right.
In summary, this patient had a sudden collapse without loss of consciousness, onset of central chest pain and upper back pain followed by vomiting. The patient had later complained of epigastralgia .
The examination had revealed a collapsing pulse and the murmur of aortic regurgitation, right basal crackles and an left renal bruit with a slight inequality of the dorsalis pedis arteries.
Pulling all the main features together to make one unifying diagnosis, it was considered to be a Proximal to Distal Dissenting Aortic Aneurysm.
CT scan showed some minor right basal lung collapse, no obvious apical problem, but the aorta was slightly abnormal.
The advice was to
- Obtain expert radiological advice on the CT scan
- Obtain an urgent cardiac echo to observe the aortic valve and to check for a potential tamponade
- To obtain a doppler study of the kidneys to assess blood flow to ascertain if there was an obstruction to the arterial orifice from a dissection.
The radiologist had confirmed that the CT findings were consistent with an aortic dissection and the patient was admitted under the appropriate specialty.
DIAGNOSIS: Aortic Dissection
This case markedly shows how a history and detailed examination with the basics of an ECG and chest Xray can lead one to the diagnosis of dissection.
Never rely purely on upper limb pulses being equal; they can be equal and there can still be a dissection.
A chest Xray can aid with the diagnosis if there is a widening of the mediastinum and in some cases there can be a left sided pleural effusion which can be a haemothorax due to the dissection. In this case, there was a left sided pleural effusion, but the effusion was not tested , so it remained unknown as to its origin.
Echocardiography is very important as it can show valvular insufficiency and tamponade.
The abdominal bruit was a gift sign in this case as it signified narrowing of an arterial foramen which suggested abdominal extension of the dissection.
The CT scan here was helpful to give more weight to the diagnosis although it was used to confirm the diagnosis rather than to make a surprise diagnosis.