Case 32

Chief complaint quote: abdominal pain and flank pain

Vital Signs: T 96.5, HR 73, RR 22, BP 268/131, SaO2 99% on 4 LPM

HPI
60-year-old male with a history of hypertension and end-stage renal status post kidney transplant p/w sudden upper and lower back pain.  The pain is severe and nonradiating. The patient has never had pain like this before. Nothing makes the pain better or worse.

Review of Systems
Constitutional: See HPI.
Eyes: No visual changes, eye pain or discharge.
ENMT: No hearing changes, pain, discharge or infections. No neck pain or stiffness.
Cardiac: No chest pain, SOB or edema. No chest pain with exertion.
Respiratory: No cough or respiratory distress. No hemoptysis..
GI: No nausea, vomiting, diarrhea, or melanotic stool. 
GU: No dysuria, urinary frequency or burning.
Neuro: No headache or weakness. No paresthesias/numbness.  No LOC.
Skin: No skin rash.
Except as documented in the HPI, all other systems are negative. 

EXAM
CONSTITUTIONAL: Well-developed; well-nourished; in no acute distress.
HEAD: Normocephalic; atraumatic.
EYES: PERRL, EOM intact; conjunctiva and sclera clear.
ENT: No nasal discharge; airway clear.
NECK: Supple; non tender.
CARD: S1, S2 normal; no murmurs, gallops, or rubs. Regular rate and rhythm.
RESP: No wheezes, rales or rhonchi.
ABD: Normal bowel sounds; soft; non-distended; non-tender; no hepatosplenomegaly.
EXT: Normal ROM. No clubbing, cyanosis or edema.
NEURO: Alert, oriented, grossly unremarkable
PSYCH: Cooperative, appropriate.

QUESTIONS

  1. Based on the following videos and clinical scenario, what is the most likely diagnosis?
  2. What is the next most appropriate medical intervention for this patient?
  3. What two layers of the aorta are most commonly affected with this condition?
  4. What is the utility of obtaining a sagittal image of the abdominal aorta?

ANSWERS

  1. Aortic Dissection.  Flap seen in image is the dissection.
  2. Blood pressure control and pain control. IV beta blockers to decrease shearing force and pain medication to reduce adrenergic response. Vascular surgery consult.
  3. Intima and media.
  4. To determine whether a saccular aneurysm may be present.