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Course 5
Case 2
Patient: female, 83 years
Part 1 – admission to hospital
Family history: Father died at 65 probably of pneumonia. Mother died at 82. Brother died
at 70 of cerebrovascular accident. Son and daughter are healthy.
Past history: Since 67 treated for hypertension. At 70 hospitalised in Bulovka for painful
pressure behind the upper sternum, concluded as pericarditis (according to the patient).
Allergy: no. Teetotaller. Non-smoker.
Medication: Gopten (trandolaprilum) 2 mg daily and MonoMack (isosorbit 5-mononitrate) 1 a
day.
History of presenting complaint: 20. 5. 2003 she suddenly felt like fainting. She was sweating
and had nausea with severe dull pain behind the sternum radiating into abdomen. This
unbearable pain is still present at admission.
Physical examination: Temperature 36,7 ºC, height 162 cm, weight 65 kg, pulse 76/min.
irregular, BP 210/100 mmHg. Slightly elevated jugular venous pressure. Carotid arteries:
Symmetrical pulse, no murmur. Lungs: Normal breathing sounds. Quiet systolic murmur 1/6
over the apex. Abdomen without resistance, liver and spleen: not enlarged. Low limbs without
edema, groins: symmetrical pulse, periphery: symmetrical pulse, poorly felt
Admission ECG:
Questions:
Course 5
Case 2
1. What is a preliminary (working) diagnosis in this phase?
2. What examinations are necessary to make a diagnosis?
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Part 2: The first hour of hospitalisation
The admission blood tests showed following results: sodium 141 mmol/l, potassium 4,38
mmol/l, urea 5,21 mmol/l, creatinine 78 umol/l, ALT 0,35 ukat/l, AST 0,30 ukat/l, glucose
7,86 mmol/l, CK 0,60 ukat/l, CK-MB 0,23 ukat/l, cholesterol 4,95 mmol/l, triglycerides 0,66
mmol/l, CRP 62,7 mg/l, leukocytes 9,5 x 109/l, erytrocytes 4,62 x 1012/l, haemoglobin 145 g/l,
hematocrit 41,9%, platelets 212 x 109/l. INR 1,01. APTT 34,6 s. Urinalysis: protein 0-1,
erytrocytes 1-3, leukocytes 0-1, sporadic epithelial cells.
Questions:
3. List abnormal blood tests values.
4. Some values are purposely expressed in incorrect units. Which ones?
Chest X-ray: several laminar lung atelectases in lower lung fields. Infiltration 2x2 cm in the
right basal anterior segment close to the heart. Heart of aortic shape, dilated to the left. Aorta
is sclerotic, aortic arch is markedly enlarged,
Transthoracic echocardiography: Left ventricular diameter 50 mm (norma 21-43), right
ventricular diameter 33 mm (norma 9 -31), left atrium 34 mm (norma 21-43). Aortic root 39
mm (norma up to 37 mm), aortic arch cannot be evaluated. Left ventricular wall thickness 10
mm (norma up to 12mm). Normal wall motion of the left ventricle, ejection fraction 65%
(norma over 55%). Small circular pericardial effusion. Aortic valve sclerosis with mild
insufficiency.
ECG recorded 30 minutes after admission: no change as compared to admission ECG
Symptoms: Continuing severe retrosternal pain radiating via abdomen up to groins. Feeling of
cold low limbs.
Question:
5. What examination must follow immediately?
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Course 5
Case 2
CT of the chest and abdomen: Ascending aorta is dilated up to 71 mm, aortic lumen is divided
by transversal hypodense strip in two 39 cm and 25 cm lumens. The two lumens are seen in
the whole course of aorta up to iliac arteries. There is a flat wall thrombus seen in the distal
ascending aorta.
Transesophageal echocardiography: Ascending aorta dilation, huge aneurysm of the aortic
arch with diameter of 62 mm. Intimal flap starting 5 cm above the aortic valve is seen in the
whole aortic course up to abdominal aorta.
Aortography:
After introduction of catheter, mean gradient of 30 mmHg is apparent between ascending
aorta and distal abdominal aorta.
Aortic root contrast injections revealed a huge enlargement of ascending aorta starting
approximately 5cm above the aortic valve. Two upward pointing arrows show the origin of
dissection (right contour of aorta on the radiographic screen corresponds to posterior aortic
wall). Eight rightward pointed arrows show calcifications in the aortic wall (left aortic contour
on the screen corresponds to anterior aortic wall). Note a dense strip along the diameters of
aneurysm representing thrombus. Upper part of the figure shows involvement of truncus
brachiocephalicus ostium in aneurysm cavity (downward pointing arrows, between number 4
and 2):
Course 5
Case 2
Questions:
6. What is the final diagnosis?
7. Explain the pathophysiology of different types of aortic aneurysms. Are there any risk
factors for aortic aneurysm?
8. Causes and consequences of hypertension
9. Aortic aneurysm – types, complications