Tuesday, 21 October 2008

An Interesting Chest Radiograph

Dear Bloggers

Here is an interesting chest radiograph of an elderly patient with an acute onset of central chest and back pain which subsequently propogated to the abdomen. On admission, the patient had hypotension and distant heart sounds. The chest radiograph (with the history and physical findings) provided the diagnosis within seconds-- a proximal to distal aortic dissection (Stanford A type / DeBakey Type I).
Echocardiography revealed pericardial blood causing tamponade and an emergency thoracic contrast CT scan revealed a large Stanford type A dissection -- as suspected!

The ECG showed no signs of myocardial infarction which would be the differential diagnosis in such a case.

Remember that in patients with acute aortic dissection, the central chest pain can be severe. It may become a tearing pain in between the scapulae (interscapular pain). Such pain may further propogate down the back and into the abdomen as the aorta further dissects. Although this CXR is a classic example of a dissection, a chest radiograph can be normal in a proximal dissection. Even though it is often quoted that the blood pressure between the arms can be unequal it is not sensitive or specific for dissection and cannot be relied upon.

Good tests for investigating dissection include the quick bedside cardiac echo to look for haemopericardium and one may sometimes see the tear of the artery near to the aortic valve. However, the gold standard examination is the emergency CT.

If you have a high suspicion of dissection, please first stabilise your patient before moving them to the CT scanner -- remember the basics of Airway, Breathing and Circulation.

Please remember to give the patient adequate pain relief e.g. diamorphine, although bear in mind the potential hypotensive effects of the drug . It is not humane to leave patients in pain.

Ensure that the patient can be transported (if feasible) to a specialist cardiothoracic centre and if already there, ensure that the surgeons are told early rather than delaying for other reasons because 'time is artery'.

Monday, 20 October 2008

A New Case For October

Dear Bloggers

This case has been anonymised for the safety of patient confidentiality and it is reported here for the teaching of Problem Based Learning.

This 74 year old lady was admitted with a history of increasing abdominal swelling and dyspnoea. The abdominal swelling started 3 months before and was gradually increasing. There was no pain associated with the swelling and the patient denied changes in bowel habit, urine colour, weight loss, appetite change or jaundice.

The dyspnoea occurred only on mobilising or lying flat and there was no report of palpitations, chest pain, cough, sputum, wheeze or haemoptysis. There was no complaint of leg swelling or paroxysmal nocturnal dyspnoea.

She had a 3 year history of rheumatoid arthritis for which she took methotrexate 12.5mg per week, Bucillamine (similar to Penicillamine), folic acid once per week and COX-2 inhibitor when required. Her RA was currently under good control.

She had been informed that she had elevated liver enzymes over 10 years ago and they were observed without intensive investigation. No cause was identified. There was no history of Hep B or Hep C virus infection, no blood transfusions, no IV drug misuse and no tattoos in the past.

She had never drank alcohol and was a non-smoker. There was no family history of note especially no inherited causes of disease. She otherwise lived independently alone and had a good support network of friends. She was unmarried and had never had children. No sexual history was taken. No gynaecological history was taken.

On examination

She patient looked well. Afebrile. No Dupytren's contracture, no hepatic flap, no palmar erythema and no spider naevae. No jaundice, no anaemia, no cyanosis, no clubbing, no lymphadenopathy. GCS 15/15.

CVS: Pulse 90/min regular, BP 110/80 mmHg, JVP slight elevation, Heart Sounds normal. No S3 or S4 and no murmurs.

RESP: RR = 30/min, sats 98% on ambient room air, trachea central and no tug, percussion stony dull at both lung bases with decreased tactile vocal fremitus. Lung sounds normal with no crackles but reduced air entry at both bases.

ABDO: Soft, grossly distended abdomen. Non-tender, no obvious masses, no hepatosplenomegally. No rebound or guarding. Bowel sounds normal. Shifting dullness with approximately moderate ascites. Evidence of a previous puncture site on the left lateral abdominal wall. No rectal exam performed.

Pelvis: No gynaecological exam performed.

Extremeties: Pitting oedema of both lower limbs and arms. IV line in left arm with containing 77 mmol Na in 500ml with daily rate at 80ml/hour.

Hands: Swollen. Finger joints normal - no pain, stiffness or restriction of motion. Normal metocarpophalangeal joints, normal wrist joints. No evidence of RA nodules at the elbows.


1) Please make a problem list from the above history and physical examination.

2) Please list several differential diagnosis and please identify one of the likely contributory causes from the history.

3) What tests would you do to confirm your hypothesis?

4) What would be your evidence based treatment strategy for such a patient?

As always, please feel free to send in your attempts at answering the case. The actual case answers will be available in approximately a week. Enjoy sleuthing :-)