Edie Waskel, D.O.
Sarah Bunch, M.D.
A 65 year-old female with history of hypertension, diabetes and asthma presents complaining of subjective fevers, nausea, and vomiting for the past two days. Today her symptoms worsened, and she developed a persistent headache and neck pain. She also reports weakness which is worse in her left upper and lower extremities. Over the past several weeks, she has also noted constant, central chest pain which she attributed to reflux. She presently denies abdominal pain, diarrhea, sore throat, nuchal rigidity, numbness or tingling, vision changes, shortness of breath, or rash.
Review of Systems
Vitals: BP 149/115, Pulse 74, Temp 98 °F (oral), Resp 16, SpO2 98% on Room Air
Neuro: ⅘ muscle strength to the left upper and lower extremities compared to right, sensation grossly intact, no facial droop, normal finger to nose and normal heel to shin bilaterally
SARS-COV-2 PCR: not detected
Lactic Acid: 1.8
CT Head or Brain w/o Contrast
No hemorrhage. No acute intracranial process by noncontrast CT.
Mild chronic microvascular ischemic disease
Old lacunar infarct right basal ganglia
Mild symmetric cerebral cortical and moderate central volume loss and mild prominence of the temporal horns and moderate cerebellar volume loss, unchanged.
Mild calcification atherosclerotic calcification carotid siphons.
Heart is mildly enlarged. Aortic is ectatic and tortuous but unchanged. There is elevation left hemidiaphragm with blunting left lateral costophrenic angle, consider scarring, pleural thickening or small pleural effusion. Left-sided Port-A-Cath in place its tip at level of the caval atrial junction. Detail is limited and followup PA and lateral views chest are recommended.
CT Abd/Pelvis w/o Contrast
No acute intra-abdominal/pelvic abnormality by noncontrast technique. Etiology of the patient's symptoms is unclear from this exam and remains to be determined and must be managed clinically.
Moderate chronic hiatal hernia
Nonobstructive 2.3 cm left renal calculus, lower pole, increased from 2 cm. Couple new tiny nonobstructive right renal calculi. No ureteral or bladder calculi. No hydroureteronephrosis. No perinephric stranding. Urinary bladder unremarkable.
Long chronic infrarenal dissection with associated infrarenal abdominal aortic aneurysm 2.3 x 2.6 cm, slightly increased from prior exam, similar morphology (previously 2.2 x 2.4 cm). No perienteric inflammatory changes/fluid collections. Suggest 5 years surveillance.
Tiny hypodense liver nodule, indeterminate but benign. If patient has risk factors for primary metastatic liver disease, follow-up MRI 6 months time may be pursued.
Additional stable findings, as above.
TIME OF SIGNOUT: Ordered one more image, pending results. Oncoming resident and attending aware...
Stanford type B dissection extending from beyond patent left subclavian artery to distal abdominal aortic bifurcation terminating in med left common iliac artery. True and false lumens patent. Patent IMA supplied by false lumen. Remaining great abdominal vessels supplied by true lumen, widely patent. No perienteric inflammatory changes or fluid collections. No pleural effusion.
Fusiform aneurysm descending aorta up to 5.0 x 5.5 cm orthogonal diameter. No periaortic inflammatory changes or fluid collections. No pericardial effusion or pleural effusion.
Click for diagnosis and more!
The aorta is histologically composed of 3 predominant layers: the tunica intima, media, and adventitia.
Personal Hx of bicuspid valve
Missed as initial presentation in as many as ⅓ of patients (often mistaken for ACS, PE, CVA, shock, HTN emergency, intra-abdominal emergency, acute limb ischemia)
Urgent surgical consultation
American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Thoracic Aortic Dissection, Diercks DB, Promes SB, et al. Clinical policy: critical issues in the evaluation and management of adult patients with suspected acute nontraumatic thoracic aortic dissection [published correction appears in Ann Emerg Med. 2017 Nov;70(5):758]. Ann Emerg Med. 2015;65(1):32-42.e12. doi:10.1016/j.annemergmed.2014.11.002