Case 5.9

Case Presentation by Dr. Andrew Klutman

CC:  “My chest hurts and the left side of my body is tingling and numb”

HPI: 82 yo female was otherwise normal until 10am this morning when her family stated that she kind of passed out. She did not hit her head as she was sitting on the couch. When she came to she complained of tingling and numbness in her left arm and leg along with rather severe chest pain. She was brought in by EMS and they stated that she was in minor distress and sitting in a chair when they arrived on seen. She also complains of a sharp chest pain she describes as below the sternum that was worse when it first started but is more mild but constant now. She has been eating and drinking without issues, and has been feeling just fine previously. She denies any fevers or chills, nausea/vomiting/diarrhea, cough, or problems urinating. However she does provide that she has feels a little SOB since being picked up by EMS when asked.

ROS: Negative otherwise noted in HPI

PMH: TIA last year, Hypertension, aortic valve replacement in 2007

PSH: Cholecystectomy in 2001

MEDS: Metoprolol

SH: Quit smoking 15 years ago. Denies drinking or elicit drug use. Lives at home with her husband.

EXAM:

Vitals: T- 37.6 oral  HR- 95 BP- 148/68 RESP- 22

GEN: In mild distress. Is alert and oriented and answers questions appropriately

CV:  Regular rate and rhythm, no murmurs noted. Upper ext pulses are 3+ and the lower ext pulses are 2+.

RESP: CTAB

GI: Non tender, non distended, positive bowel sounds

EXT: 5+ strength in both upper and lower extremities.

HENT: Normal cephalic, no facial droop or asymmetry noted.

NEURO: All extremities are intact to soft touch

Labs: Abnormalities: WBC – 12, electrolytes are WNL, INR – 1.6

EKG:

CXR:

QUESTIONS:

What is the most likely diagnosis?
a) Cardiac tamponade
b) PE
c) Stroke
d) Aortic dissection

What subjective finding helps most in delineating MI from the above diagnosis?
a) Tingling/numbness on the left side of the body
b) Substernal chest pain
c) Sudden severe chest pain that was worse upon onset
d) Radiation up into the jaw

Roughly what percentage of patients with this diagnosis are initially confused for MI or something else upon initial presentation?
a) None
b) 100%
c) 72.655 %
d) 38 %

Discussion & Answers

1)    D

2)    C

3)    D

What is the most likely diagnosis?
a) Cardiac tamponade
b) PE
c) Stroke
d) Aortic dissection

Aortic dissection is a great imitator.  There are several physical exam findings is this case that help guide you toward the diagnosis. First, she is hypertensive which is a common finding and also cause of a dissection. The hypertension is related to a combination of the underlying factors that led to the dissection, a resulting catecholamine surge and/or the false lumen compressing and narrowing the true lumen. The narrowing, for all intent and purposes, “stenosis” the true lumen increasing the overall pressure proximal to the involved portion of the aorta. It’s important to note that dissections can also present with hypotension which should make you think tamponade, rupture or MI from involvement of the coronaries if the diagnosis of dissection is being considered. The narrowing also causes the difference in peripheral pulses which makes sense. I like to kind of think of it as being similar to a coarctation where the blood pressure is less distally to the dissection making it less easily palpated in the lower extremities. Next, the wide pulse pressure is likely due to the tear extending into the aortic valve resulting in aortic regurgitation. Remember she previously had a valve replaced? Valve replacement can help precipitate the dissection.  The CXR shows widening of the mediastinum. An estimated 62 percent of patients with a dissection have a widened mediastinum. However, nearly 12% are read as normal.

As far as the subjective findings, the patient “passed out.” 5% of patients with aortic dissection will experience a syncopal episode. She also states that she is short of breath which can be a result of the dissection compressing a main stem bronchus. Other symptoms to look for include dysphagia from the esophagus being compressed, flank pain from renal artery involvement in the dissection, and of course stomach pain from a descending dissection occluding a mesentery vessel.

What subjective finding helps most in delineating MI from the above diagnosis?
a) Tingling/numbness on the left side of the body
b) Substernal chest pain
c) Sudden severe chest pain that was worse upon onset
d) Radiation up into the jaw

Dissection can look like an MI. The classical substernal ripping/tearing sensation that radiates to the back is not always the case. In fact, 10% of patients with dissection present with no pain at all, while others present with more mild symptoms that look like musculosketal pain. As far as MI vs dissection, they both can cause substernal chest pain (aortic root) and both can even radiate into the neck or jaw (aortic arch). In addition to all this, dissections into the cardiac vessels can an STEMI with elevated troponins.  So, the fact that the pain is more severe at onset is a clue that the patient is likely dissecting. This subjective finding was highlighted by several sources as being a focal finding during initial presentation that should clue us in that dissection needs to be considered.

Roughly what percentage of patients with this diagnosis is initially confused for MI or something else upon initial presentation?
a) None
b) 100%
c) 72.655 %
d) 38%

MI and musculoskeletal pain are not the only contributors to the confusion. In fact, 38% dissections are missed upon initial presentation. 20% of dissections have neurological manifestations which can make you think stroke. Patients can present with hemiparesis, hemianesthesia or weakness. If the cervical ganglion is affect, dissection patients can present with Horner’s syndrome. If that was not enough, peripheral nerve ischemia may manifest with numbness and tingling, pain, or weakness in the extremities. The bottom-line is to keep dissection in your differential when working up chest pain as it has a very high morbidity and mortality and has a high probability of being initially missed.

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