Help Needed on CV Problem!!!

[bt9099]

53y/o obese woman with HTN is brought to ER. Had excruciating stabbing like chest pain readiating to left arm. Puls 110, BP is 160/80. Heart souds distant, pulsus paradoxus persent. ECG shows low voltage ST-T wave changes. Xray shows widening of mediastinum. Most likely dx:

a. aortic disssection with cardiac tamponde
b. massive pulmonary thromboembolism
c. MI with congestive failure
d. rupture of papillary muscle


Guys, is the answer really A? Do you ohave ST elevations in aortic dissection and/or cardiac tamponade? I didnt think this was possible, could someone pls help me on why it cant be the other choices, epecially C and D????

Dont you get lowered BP in aortic dissection and cardiac tamponade???

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[Nicholaus]

53y/o obese woman with HTN is brought to ER. Had excruciating stabbing like chest pain readiating to left arm. Puls 110, BP is 160/80. Heart souds distant, pulsus paradoxus persent. ECG shows low voltage ST-T wave changes. Xray shows widening of mediastinum. Most likely dx:

a. aortic disssection with cardiac tamponde
b. massive pulmonary thromboembolism
c. MI with congestive failure
d. rupture of papillary muscle


Guys, is the answer really A? Do you ohave ST elevations in aortic dissection and/or cardiac tamponade? I didnt think this was possible, could someone pls help me on why it cant be the other choices, epecially C and D????

Dont you get lowered BP in aortic dissection and cardiac tamponade???

Answer = A (100% sure)
I highlighted the buzz words!!

 

[bt9099]

quote=Nicholaus;6805894]Answer = A (100% sure)
I highlighted the buzz words!! [/quote]


I got the buzzwords, but thats not why im confused...how do you have ST elevation in this case for example??? And also the other questions I had in my original post....


thank you

 

[VPDcurt]

It has to be A. The patient is bloated and has HTN so aneurysm is likely. The distant heart sounds and pulsus paradoxus are basically giving it away that there is cardiac tamponade which is due to the dissection of the aneurysm into the pericardium. The mediastinal widening on xray is from the aortic aneurysm, as is the widened pulse pressure due probably to aortic regurg from dilation of the valve. The other answer choices don't really make any sense.

 

[agranulocytosis]

I got the buzzwords, but thats not why im confused...how do you have ST elevation in this case for example??? And also the other questions I had in my original post....


thank you

How do "low voltage ST-T wave changes" equal "ST elevation"? I don't think the question is showing the same thing.

As for the other s/s, know that things are not always static and classical problems may not present classically. The important thing is to pick out what's most important to the question at hand and not the ancillary details that may or may not be distractors.

 

[VPDcurt]

You get the ST changes (I think it's usually depression) because blood flow through the coronaries is basically shot - the damn thing just dissected through the aortic valve.

 

[VPDcurt]

It's basically aortic dissection/MI/cardiac tamponade - which is all sequential when you think about it. And that's why none of the other answers make sense. The other answer choices can account for one or two of the presenting signs, but answer A is the only one that accounts for all of them.

 

[ROBINHO]

Read the question again.
There is no mention of ST elevation
They are talking about the VOLTAGE

 

[VPDcurt]

Dont you get lowered BP in aortic dissection and cardiac tamponade???

Lowered BP? Her BP is 160/80 - not exactly hypotensive.

 

[synapse lapse]

Lowered BP? Her BP is 160/80 - not exactly hypotensive.

That's his point. You should see lowered bp in a dissection. Everything else fits but that seems wrong.

Edit: wiki says the presentation is variable with bp being hyper/hypotensive in aortic dissection.

 

[VPDcurt]

True. But usually you see low BP when it is in the abdominal aorta/retroperitoneal - there isn't an awful lot of space for it to bleed out in the pericardium. right?

 

[GynGuy1983]

True. But usually you see low BP when it is in the abdominal aorta/retroperitoneal - there isn't an awful lot of space for it to bleed out in the pericardium. right?

But isn't cardiac tamponade associated with hypotension? That's at least what I thought and so did Dr. Beck with his triad of JVD, hypotension, and muffled heart sounds. The one thing that would have tipped me off to the tamponade though would have been the distant heart sounds due to accumulation of fluid in the pericardium and the sharp, excruciating pain.

As for the other answer choices, I doubt that the patient had a saddle embolus as the patient was not presenting with tachypnea or cyanosis, or some other reason by they would throw a clot. CHF would be a stretch, so that rules out B and C. As for D, I highly doubt that the patient would have even had time to say that her shoulder hurt. She would have just gone into shock, which wasn't mentioned in the vignette.

 

[docmd2010]

ST changes could also be due to pericarditis secondary to blood in the mediastinum. Blood coming near the pericardial membrane causes irritation and this could precipitate an inflammatory response. St elevation is classically seen in pericarditis.

 

[Pontifex Maximus]

B doesn't make sense for obvious reasons.
C, a simple MI + CHF wouldn't cause pulsus paradoxus or widening of the mediastinum
D is a possibility if it caused tamponade, but unlikely.

A is the only one that really fits.

 

[VPDcurt]

But isn't cardiac tamponade associated with hypotension? That's at least what I thought and so did Dr. Beck with his triad of JVD, hypotension, and muffled heart sounds. The one thing that would have tipped me off to the tamponade though would have been the distant heart sounds due to accumulation of fluid in the pericardium and the sharp, excruciating pain.

Yeah you're right about that. I guess that's why we're supposed to choose the "best" answer.