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Clinical Skills Challenge - case 4

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A 78-year-old man has a shopping trip interrupted by severe chest pains. Can you correctly diagnose his condition?

THE COMPETITION FOR THIS CASE STUDY IS NOW CLOSED. THE ANSWERS ARE AT THE BOTTOM OF THE PAGE.

Click here to download a printable PDF of this article (recommended)

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.

Click here for a PDF of this case study, including chest x-ray.

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.

  • The cold and mottled left arm could suggest that the brachial artery branches have been affected.

  • The chest x-ray shows a very marked widening of the mediastinum classically seen in thoracic aortic dissection.

  • The ischaemic ECG changes and raised troponin would suggest that there has also been coronary artery involvement.

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