Help Needed on CV Problem!!!

Discussion in 'Step I' started by bt9099, Jun 19, 2008.

  1. bt9099

    2+ Year Member

    Joined:
    Mar 30, 2008
    Messages:
    41
    Likes Received:
    1
    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???
     
  2. Nicholaus

    Nicholaus Fellow
    7+ Year Member

    Joined:
    Dec 9, 2007
    Messages:
    114
    Likes Received:
    0
    Answer = A (100% sure)
    I highlighted the buzz words!! :D
     
  3. bt9099

    2+ Year Member

    Joined:
    Mar 30, 2008
    Messages:
    41
    Likes Received:
    1
    quote=Nicholaus;6805894]Answer = A (100% sure)
    I highlighted the buzz words!! :D
    [/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
     
  4. VPDcurt

    VPDcurt 2K Member
    10+ Year Member

    Joined:
    Jul 20, 2004
    Messages:
    2,644
    Likes Received:
    23
    Status:
    Attending Physician
    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.
     
  5. agranulocytosis

    Physician 10+ Year Member

    Joined:
    Sep 22, 2007
    Messages:
    557
    Likes Received:
    28
    Status:
    Fellow [Any Field]
    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.
     
  6. VPDcurt

    VPDcurt 2K Member
    10+ Year Member

    Joined:
    Jul 20, 2004
    Messages:
    2,644
    Likes Received:
    23
    Status:
    Attending Physician
    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.
     
  7. VPDcurt

    VPDcurt 2K Member
    10+ Year Member

    Joined:
    Jul 20, 2004
    Messages:
    2,644
    Likes Received:
    23
    Status:
    Attending Physician
    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.
     
  8. ROBINHO

    ROBINHO Junior Member
    10+ Year Member

    Joined:
    Dec 27, 2004
    Messages:
    398
    Likes Received:
    32
    Status:
    Resident [Any Field]
    Read the question again.
    There is no mention of ST elevation
    They are talking about the VOLTAGE
     
  9. VPDcurt

    VPDcurt 2K Member
    10+ Year Member

    Joined:
    Jul 20, 2004
    Messages:
    2,644
    Likes Received:
    23
    Status:
    Attending Physician
    Lowered BP? Her BP is 160/80 - not exactly hypotensive.
     
  10. synapse lapse

    synapse lapse tokyo robotic
    15+ Year Member

    Joined:
    Mar 14, 2003
    Messages:
    1,671
    Likes Received:
    2
    Status:
    Attending Physician

    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.
     
  11. VPDcurt

    VPDcurt 2K Member
    10+ Year Member

    Joined:
    Jul 20, 2004
    Messages:
    2,644
    Likes Received:
    23
    Status:
    Attending Physician
    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?
     
  12. GynGuy1983

    GynGuy1983 C&A Psychiatry Fellow
    7+ Year Member

    Joined:
    Jun 13, 2008
    Messages:
    138
    Likes Received:
    18
    Status:
    Fellow [Any Field]
    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.
     
  13. docmd2010

    docmd2010 Senior Member
    7+ Year Member

    Joined:
    Apr 17, 2005
    Messages:
    523
    Likes Received:
    2
    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.
     
  14. Pontifex Maximus

    Pontifex Maximus Rads-a-palooza
    Physician 10+ Year Member

    Joined:
    Mar 18, 2003
    Messages:
    2,757
    Likes Received:
    5
    Status:
    Resident [Any Field]
    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.
     
  15. VPDcurt

    VPDcurt 2K Member
    10+ Year Member

    Joined:
    Jul 20, 2004
    Messages:
    2,644
    Likes Received:
    23
    Status:
    Attending Physician

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

Share This Page