Case 19

65 yo F with PMH significant for HTN, COPD, breast ca p/w chest pain and back pain. Pt describes pain as constant, worse with exertion and associated with shortness of breath. Pt was seen by cardiologist and referred to ED for further evaluation.

ROS:

Constitutional: No fever/chills,
Cardiac: +chest pain, +SOB, no palpitations
Respiratory: No cough or respiratory distress, +SOB with exertion
Abdomen: No nausea/vomiting, no diarrhea/constipation
Skin: No skin rash

Exam:

Vitals: T 97.9F, BP 201/128, HR 100, RR 20, Pulse ox 89% in RA

Constitutional: anxious, well-dressed, no acute distress
Card: Normal S1 and S2, tachy, no murmurs/rubs/gallops
Resp: Lungs CTA b/l, no wheezes/rales/rhonchi
Abdomen: Soft, nontender, nondistended, normal bowel sounds
Ext: Normal ROM, no clubbing, cyanosis or edema
Neuro: Alert, anxious, oriented x 3

Questions:

  1. What is the image in Figure A?
  2. What is abnormal about Figure A?
  3. What do you see in this sagittal view in Figure B?
  4. What view of the heart is in Figure C?
  5. What is the abnormal measurement in Figure C depicting?

Figure A

Figure B

Figure C

Answers:

1. What is the image in Figure A?

Distal aorta

2. What is abnormal about Figure A?

The size of the distal aorta should be less than 3 cm. Significant

abdominal aneurysms (i.e., high risk of rupture) are usually greater

than or equal to 5 cm in diameter with a fusiform shape. AAAs < 4 cm

have a 2% per year risk of rupture, AAAs 4-5 cm have a 3-12% per year

risk of rupture, and AAAs > 5 cm have a 25-41% risk of rupture.

3. What do you see in this sagittal view in Figure B?

You are seeing the sagital view of the aorta, which shows a saccular

outpouching, consistent with an aneurysm. Remember that we do not

measure the aorta when imaging it longitudinally because it is easy to

get an image off midline, known as the cylinderical tangential effect.  In this view, we are simply trying to

ensure that saccular outpouchings of the aortic wall are not missed.

4. What view of the heart is in Figure C?

Parasternal long, which shows the left ventricle, mitral valve, left

atrium, aortic outflow, descending thoracic aorta and right ventricle.

5. What is the abnormal measurement in Figure C depicting?

Distal thoracic aorta, which is > 3 cm.

References:

Noble VE, MD, Nelson B, MD. Manual of Emergency and Critical Care

Ultrasound 2nd Ed. Cambridge: Cambridge University Press, 2011. Print