Maintain pressure on reforms to protect NHSClinical Skills Challenge - case 4
A 78-year-old man has a shopping trip interrupted by severe chest pains. Can you correctly diagnose his condition?
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This 78-year-old man was admitted at 2pm with severe chest pain.
History of presenting complaint
He was in the town centre with his wife and was walking along carrying two small bags of shopping. He was suddenly stopped in his tracks by an intense pain in his chest that quickly moved through to his upper back. The onset was very acute and he described it as being like a knife being plunged into his back. He fell to his knees.
He became very distressed and extremely short of breath.
On admission
He is terrified and distressed. He is still complaining of an intense and sharp pain between his scapula and to a lesser extent in his chest. He had received Morphine 10mg IV from the Paramedics. The pain in his chest is perhaps of a different nature and is more of an ache compared to the sharp pain in his back.
He is clammy and pale with signs of peripheral cyanosis. His left arm is very obviously cold and mottled.
Past medical history
Hypertension for 12 years
Table 1: Vital signs on admission
Blood pressure | 85/45 mmHg in right arm but unrecordable in the left arm |
Pulse | Rate 110 per minute and regular |
Respiratory rate | 28 per minute |
Temperature | 36.4oC |
Oxygen saturation | 89% on 6 litres of oxygen |
A 12-Lead ECG was recorded and reported as follows:
Sinus tachycardia rate 106 per minute. Normal cardiac axis. There is 4-6 mm ST segment depression in the chest leads C1 – C6.
Occasional uniform ventricular ectopics noted.
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Bloods
His full blood count and U&E’s were all within normal limits.
Troponin T 6 hours after admission was positive.
Arterial blood gas showed normal acid base balance with hypoxia. PO2was 9.2 kPa on 6 litres of oxygen Case study challenge
Submit your diagnosis
Comment on this mans presentation and suggest a possible diagnosis and priorities in his management. Email what you think the diagnosis is to Charlie.bloe@cb-training.com for a chance to win a FREE place on any Charles Bloe online training course.
Answer to this case study The diagnosis is thoracic aortic dissection. The main presenting feature is chest and mid scapular pain. The extremely acute onset is rather less typical of myocardial infarction and perhaps more so of aortic dissection. Some of the vital signs and observations would raise also suspicions.
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