EM Forum Case #95 "It’s Higher than
You Think"
by Charlene Babcock Irvin, MD, FACEP
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A 38 y/o obese man presents with chest pain that started after he coughed and
sneezed at the same time. It was very strong initially (10/10), but then it
eased up. He is still having the pain (6/10), so he came to the ED for
evaluation. He said it felt like something ‘pulled’ in his chest and points to
the substernal area. The pain came on suddenly with the sneeze, has no
radiation, and now feels like an ache. The pain does get worse when he takes a
big breath. It started about 4 hours ago, and is only minimally relieved by
ibuprofen. He has never had pain like this before.
PMH: Hypertension (he is on Dyazide). No hospitalizations or surgeries.
SH: Smoker, although he is cutting down; currently at 1/2 pack per day.
FH: HTN only.
ROS: No fevers, chills, cough, shortness of breath, vomiting, headache,
weakness, numbness, change in vision, diarrhea, problems with urination,
abdominal pain, or rashes.
PE: Obese man, (280 lbs) appears comfortable, but has diaphoresis noted on his
forehead.
VS: BP=155/88, P=95, RR=20, Temp=98.6F, Sat=97% on Room air.
HEENT: Unremarkable; short neck, no JVD.
HEART: RRR, no murmurs, rubs or gallop.
LUNGS: Clear bilaterally, no wheezing or rales.
CHEST WALL: Mild tenderness along the anterior sternal-costal area on the right.
His ‘ache’ chest pain is different, but palpation does partially reproduce the
pain that gets worse when he takes a deep breath.
ABD: Obese, soft, non-tender.
EXT: Unremarkable, pulses symmetric and present.
NEURO: Non-focal, and unremarkable.
Questions:
1. What are the important risk factors for development of aortic dissection?
Which is the most important risk factor?
2. How often is the CXR normal? What are you looking for when it is abnormal?
3. How often can patients with dissection present without chest pain?
4. Describe the DeBakey and Sanford classification.
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