Case 23

71 y/o M with history of HTN, HPL, PVD , MI in past s/p cabg who is a frequent smoker who presents with chief complaint of leg pain, nontraumatic, with SOB for past 10 days. No fever/chills/cough/loc.

ROS:

Constitutional: No fever, no chills, unexplained weight change or malaise.
Eyes: No visual changes, eye pain or discharge.
Cardiac: + CP
Respiratory: See HPI.
GI: No nausea, vomiting, diarrhea or abdominal pain.
MS: + leg pain
Neuro: No numbness
Skin: No skin rash. 
Endocrine: + diabetes
Except as documented in the HPI, all other systems are negative.

PE:

VS- T- 95.9 Oral. P-89, RR-24, BP-123/60 Sat-89% ra
CONSTITUTIONAL: Well-appearing; well-nourished; in no apparent distress.
HEAD: Normocephalic; atraumatic.
EYES: PERRL
NECK: Supple; non-tender; no cervical lymphadenopathy. No JVD. 
CHEST: Normal chest excursion with respiration. 
CARDIOVASCULAR: Normal S1, S2; no murmurs, rubs, or gallops. 
RESPIRATORY: Normal chest excursion with respiration; breath sounds clear and equal bilaterally; no wheezes, rhonchi, or rales.
GI/GU: Normal bowel sounds; non-distended; non-tender; no palpable organomegaly. + heme positive brown stool
BACK: No evidence of trauma or deformity. Non-tender to palpation. 
PELVIS: No evidence of trauma or deformity. 
EXT: Normal ROM in all four extremities; non-tender to palpation; diminished DP pulses (detected with doppler) + left 4th digit amputation.
SKIN: + mottling of left foot
NEURO: A & O x 4; grossly unremarkable.

LACTIC ACID 6.3
D-DIMER 317

Questions: 

  1. What are your differential diagnoses in this case?
  2. What ultrasound exams could help you narrow your differential in this patient?
  3. What are the five views obtained in an abdominal aorta study?
  4. What defines an abdominal aortic aneurysm on ultrasound?
  5. Why should you not rely on a measurement in the sagittal aorta plane?
  6. What do you see in Figure A?
  7. What do you see in Figure B?

Figure A

Figure B

Answers:

  1. The differential diagnoses include pulmonary embolism, acute coronary syndrome, aortic dissection, PNA, deep vein thrombosis, abdominal aortic aneurysm.
  2. Doing DVT, cardiac, lung, and aorta exams.
  3. They are transverse views of the proximal, mid, and distal aorta; transverse views of the iliacs; and a sagittal view of the aorta.
  4. Aortic diameter >3cm.  (Iliac aneursym should be considered for a diameter >1.5 cm.)
  5. This is unreliable because of the cylindrical tangential effect.  When a tubular structure such as the aorta is imaged in a longitudinal plane, if the beam is just off of midline, the diameter measured could underestimate the true diameter of the vessel.  The sagittal view is primarily used to evaluate for saccular aneurysm.
  6. Figure A shows a thrombus in the distal aorta.  (Although, without further imaging or a secondary view- as seen in Picture B, this could have the linear, flap-like appearance of an aortic dissection.  Make sure to always view the area of interest in two planes!)
  7. Figure B shows a saccular aneurysm.