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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? __________________________________________________________________________ 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? ________________________________________________________________________ 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