CV question

[crimsonkid85]

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53yo F w/ HTN brought to ED after collapsing. Prior to admission, she had stabbing chest pain radiating to left shoulder. Pulse 110, BP 160/80. Heart sounds distant, pulsus paradoxus is present. ECG shows low voltage and ST wave changes. CXR shows widening of mediastinum. Dx?

a. aortic dissection with cardiac tamponade
b. HTN crisis
c. massive pulmonary thromboembolism
d. myocardial infarct with congestive failure
e. rupture of papillary muscle

So, choice A sounds tempting, b/c of the distant heart sounds and pulsus paradoxus, but I thought aortic dissection was supposed to be chest pain radiating to the BACK--and not shoulder? Also, in cardiac tamponade, wouldn't you expect HYPOtension because of decreased CO--so I'm confused why the BP is 160/80?

Then I thought -- well ECG and with classic chest pain maybe = MI and she ruptured papillary muscle so is having acute mitral regurg? But then that doesn't explain any of the muffled heart sounds, etc etc.

And the other choices don't make sense.

<---- confused, help!

 

[rahulb]

pretty much pathognomonic for cardiac tamponade. dissection of the ascending aorta can cause tamponade. low voltage EKG confirms fluid in the pericardial sac. widened pulse pressure is seen in aortic regurg and aortic stiffening, widening of the mediastinum is further evidence. the only thing missing is jugular distention.

an MI would present with crushing chest pain and ST segment elevation

 

[crimsonkid85]

pretty much pathognomonic for cardiac tamponade. dissection of the ascending aorta can cause tamponade. low voltage EKG confirms fluid in the pericardial sac. widened pulse pressure is seen in aortic regurg and aortic stiffening, widening of the mediastinum is further evidence. the only thing missing is jugular distention.

an MI would present with crushing chest pain and ST segment elevation

so she DOES have aortic regurg....just due to the dissection?

 

[OveractiveBrain]

its a multiple choice test question. Stop over thinking it.

"Widened Mediastinum" --> Dissection
"Pulsus Paradoxus and Muffled Heart Sounds" --> tamponade
"HTN" risk factor for dissection
Would it help if they said "tearing chest pain radiating to the back?"

Where else do you get "buzz phrases" (since they dont use buzzwords, you have to translate buzz phrases)

Also, tearing open your aorta down to the aortic root, you can imagine, might rip open your valve a tid-bit (regurg). You should take a peek at Robbins cardiovascular chapter and look at Dissecting Hematoma if you're still confused.

 

[PBandJ]

I think the BP depends on where they took it, and it all depends on what type of dissection it is (DeBakey 1, 2, or 3). I know we shouldn't believe everything we read on wikipedia, but this actually explains it pretty well:

Blood pressure changes
While many patients with an aortic dissection have a history of hypertension, the blood pressure is quite variable at presentation with acute aortic dissection, and tends to be higher in individuals with a distal dissection. In individuals with a proximal aortic dissection, 36% present with hypertension, while 25% present with hypotension. In those that present with distal aortic dissections, 70% present with hypertension while 4% present with hypotension.
Severe hypotension at presentation is a grave prognostic indicator. It is usually associated with pericardial tamponade, severe aortic insufficiency, or rupture of the aorta. Accurate measurement of the blood pressure is important. Pseudohypotension (falsely low blood pressure measurement) may occur due to involvement of the brachiocephalic artery (supplying the right arm) or the left subclavian artery (supplying the left arm).

So I agree that hypotension would be more likely in the case of cardiac tamponade, but I guess even there you can have variations.

 

[OveractiveBrain]

People, the question is about a Dissecting Hematoma, not about the tamponade. The whole question is swarming with HELLO, I HAVE THE RISK FACTORS AND PRESENTATION OF A DISSECTION, and the question cleverly adds, "whats a complication." diagnosis from the mileu of buzzwords is dissection. Complication? Tamponade from involvement of the aortic root.

No one gives a hoot which grade, debakey, or ninja clown version it is. Its a stupid Step 1 Question. Analyze it like a step 1 question rather than write a paper about it.

Also Wikipedia blows. Its for people that understand. You are a medical student, you should be blindly memorizing word associations. Its what the Step 1 is all about!