chest pain case 2

Chest pain Case 2

A 52-year-old man presents to the emergency department because of severe chest pain. The excruciating pain began abruptly, 30 minutes
previously, and feels to the patient as if something were "ripping." When asked to point to where the pain is worst, the patient points to the
precordium. The man additionally reports that the pain seems to be changing in position slowly.


Question 1 of 6
Which of the following is most likely causing the patient's severe pain?
/ A. Aortic dissection
/ B. Atherosclerotic aortic aneurysm
/ C. Esophageal reflux
/ D. Myocardial infarction
/ E. Peptic ulcer


Question 2 of 6
Extension of this patient's disease process would be most likely to produce which of the following?
/ A. Aortic insufficiency
/ B. Aortic stenosis
/ C. Mitral insufficiency
/ D. Mitral stenosis
/ E. Tricuspid stenosis


Question 3 of 6
If enzyme chemistries were sent, which would be the most likely results?
/ A. Decreased AST, elevated CK, decreased LDH
/ B. EIevated AST, elevated CK, normal to decreased LDH
/ C. EIevated AST, normaI CK, normaI LDH
/ D. NormaI AST, elevated CK, elevated LDH
/ E. NormaI AST, normaI CK, normal to elevated LDH


Question 4 of 6
If surgery is necessary to repair this problem, the surgeon will be required to understand the anatomic relationship of the aorta to the
surrounding structures. Which of the following most accurately describes the descending portion of the thoracic aorta?
/ A. It descends on the right side of the thoracic vertebrae
/ B. It flattens the posterior aspect of the trachea
/ C. It is to the left of the esophagus at the hiatus
/ D. It is to the left of the thoracic duct at the T10 Ievel
/ E. It is to the right of the inferior vena cava


Question 5 of 6
Which of the following would be most likely to be seen on pathological examination of a specimen removed from this patient at surgery?
/ A. Bacterial vegetations
/ B. Cystic medial degeneration
/ C. Multiple small granulomas
/ D. Parasitic organisms
/ E. Polyarteritis nodosa


Question 6 of 6
Which of the following conditions has been associated with this patient's disease?
/ A. Cushing syndrome
/ B. Dandy-Walker syndrome
/ C. Kawasaki syndrome
/ D. Marfan syndrome
/ E. Tourette syndrome


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Chest pain Case 2 answers

Q1
The correct answer is A. This patient has a classic presentation of aortic dissection. Any time a patient in excruciating chest pain describes the pain as "tearing" or "ripping," you should strongly consider the diagnosis of aortic dissection. The pain may move with time as the dissection progresses. Aortic dissection is a highly lethal condition that may lead to aortic rupture, most often into the pericardial cavity or left pleural space. The two most common sites of origin of the dissection are in the proximal aorta within 5 cm of the aortic valve and in the descending thoracic aorta just distal to the origin of the left subclavian artery. CT scan with contrast is often used to confirm the diagnosis suspected clinically. Therapy is promptly initiated with medications that lower the blood pressure to try to prevent extension of the dissection. Surgery is usually then performed in patients in which the dissection begins in the proximal aorta near the aortic root; medical therapy alone can sometimes be used for those with distal aortic dissection that has not compromised blood flow to limbs or organs.
Atherosclerotic aortic aneurysm (choice B) more commonly involves the abdominal aorta, and, when rupturing, may produce excruciating pain that is usually referred to the lower abdomen and back.
The pain of esophageal reflux (choice C) is rarely excruciating, and usually does not produce a ripping or tearing sensation.
Myocardial infarction (choice D) can produce severe precordial chest pain, but the pain usually does not move with time and does not have a tearing or ripping character.
Peptic ulcer pain (choice E) may be severe and referred to the chest, but patients are more likely to use terms like "burning" than ripping or tearing, and the pain does not slowly change position.


Q2
The correct answer is A. Dissecting aneurysms tend to start near the root of the aorta, and aortic insufficiency is a common complication. This can be very helpful in the initial evaluation of the patient, since up to 2/3 of the patients with proximal aortic dissection demonstrate, on auscultation, the characteristic murmur of aortic insufficiency, which is a pandiastolic decrescendo murmur that is loudest over the sternum and left lower sternal border. Aortic stenosis (choice B) usually does not occur.
Involvement of the mitral (choices C and D) and tricuspid valves (choice E) would be very rare, and probably only seen if the aortic dissection interrupted the orifices of the coronary arteries and induced a secondary myocardial infarction.


Q3
The correct answer is E. Unless aortic dissection secondarily causes a myocardial infarction secondary to occlusion of the coronary arteries, aspartate aminotransferase (AST) and creatine kinase (CK) levels should be normal. Lactic dehydrogenase (LDH) levels may be normal, or elevated if some hemolysis is occurring within the area of dissection.
In general, AST can be elevated (choices B and C) in a variety of cardiac diseases (e.g., myocardial infarction, heart failure, myocarditis, pericarditis), muscle damage (e.g., myositis, muscular dystrophy, trauma), and damage to liver, pancreas, kidney, or brain. AST is decreased (choice A) in pyridoxine (vitamin B6) deficiency and in the terminal stages of liver disease. In general, CK can be elevated (choices A, B, and D) in disease or damage involving heart, muscle, or brain. Decreased CK has no medical significance. Lactic dehydrogenase (LDH) can be elevated (choice D) in myocardial infarction, pulmonary infarct, hemolytic and pernicious anemia, hematologic malignancies, and disease of liver, kidney, or brain. Decreases in LDH (choices A and B) are not medically significant.


Q4
The correct answer is D. The thoracic duct is the main lymphatic duct and it lies on the bodies of the inferior seven thoracic vertebrae. It conveys most of the lymph of the body to the venous system. It passes superiorly from the cisterna chyli (the expanded inferior end of the thoracic duct) through the aortic hiatus in the diaphragm. The thoracic duct ascends in the posterior mediastinum, on the right of the thoracic aorta and to the left of the azygos vein. At the level of T4, T5, or T6, the thoracic duct crosses to the left, posterior to the esophagus and ascends to the superior mediastinum. The thoracic duct empties into the venous system near the union of the left internal jugular and subclavian veins.
As a continuation of the aortic arch, the descending aorta begins on the left side of the inferior border of the body of the T4 vertebra and descends in the posterior mediastinum on the left sides of T5 to T12 (choice A).
The trachea travels in the superior mediastinum and does not have direct contact with the descending thoracic aorta. The trachea is kept patent by a series of C-shaped tracheal cartilages. The posterior aspect is flat where it is applied to the esophagus, not the aorta (choice B).
At the level of the esophageal hiatus (choice C), the esophagus lies anterior to the descending thoracic aorta.
The inferior vena cava (choice E) is located to the right of the abdominal aorta, not the thoracic aorta. The IVC returns blood from the lower limbs, most of the abdominal wall, and the abdominopelvic viscera. This vessel begins anterior to L5 vertebra by union of the common iliac veins. It then ascends on the right psoas major muscle to the right of the median plane and aorta. It passes through the vena caval foramen in the diaphragm at the level of T8 to enter the right atrium.


Q5
The correct answer is B. Cystic medial degeneration is a disruption and fragmentation of the elastic tissue in aortic media, with formation of areas devoid of elastin. These changes weaken the aortic wall, predispose for dissection, and are seen in the majority of cases of aortic dissection.
Bacterial vegetations (choice A) are a feature of endocarditis.
Multiple small granulomas (choice C) can be seen in temporal arteritis and Takayasu arteritis.
Parasitic organisms (choice D) do not usually affect the aorta; the organisms of trichinosis and Chagas disease can affect the heart.
Polyarteritis nodosa (choice E) is a focal inflammation that usually involves smaller blood vessels than the aorta.


Q6
The correct answer is D. Marfan syndrome is an autosomal dominant connective tissue disease characterized by skeletal changes (e.g., tall stature, long limbs, long fingers, lax joints), a tendency to develop dislocations of the lens of the eye, and a tendency to develop aortic dissection secondary to prominent cystic medial degeneration in the aortic media. A similar condition, Ehlers-Danlos syndrome, also predisposes for dissecting aneurysm. Other predisposing factors include congenital cardiovascular abnormalities (e.g., coarctation of the aorta, patent ductus arteriosus, bicuspid aortic valve) that increase the turbulence of blood flow in the aorta, atherosclerosis, and trauma (including iatrogenic trauma during arterial catheterization and cardiovascular surgical procedures). The other conditions listed in the choices are unrelated to aortic dissection.
Cushing syndrome (choice A) is a characteristic pattern of physical changes (truncal obesity, moon face, buffalo hump), biochemical/hormonal changes (hypertension, altered carbohydrate and protein metabolism, amenorrhea), and sometimes psychiatric disturbances that are seen in patients with increased levels of adrenocortical hormones.
Dandy-Walker syndrome (choice B) is a congenital abnormality of the cerebellum and fourth ventricle.
Kawasaki syndrome (choice C) is a febrile childhood disease that predisposes for the formation of tiny aneurysms of the coronary arteries.
Tourette syndrome (choice E) is a motor and vocal tic disorder.