King
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37yr man ,ED 1hr after acute onset of tearing ant chest pain . pain radiates to the left back and arm he is 203 cm wt 86 kg BMI 21kg/m2 . temp36.7c pulse 116 resp 20 bl.p. 115/70 lungs clear Ecg shows no abnormality.......Diagnosis??
A angina
B aortic dissection
C aortic stenosis
H dissecting aortic aneurysm
N hepertrophic cardiomyopathy
U pneumonia
V pneumothorax
W pulm. embolus
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| cbenitesch
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Clueless... ECG is the gold standar for AMI, whithin 30 minutes pain started. Radiating pain to the left arm and left back can go with AMI. Tearing chest pain goes with aortic dissection, but donīt have BP difference between right and left arm. Aortic Aneurysm usually occurs in Abdominal Aorta. Aortic stenosis, we donīt have any heart murmur. But the guy is too tall and he is 10 kg under his ideal body weight... maybe thatīs the clue.
Iīll go with angina or could be pulm embolus 
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| frank100
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(b) typical history of aortic dissection. this guy is very tall, so marfanīs can support the answer...
a. at least ecg must have been positive.
c.not typical chest pain, not a murmur described, othing pointing towards (c)
h.no history enough for marfanīs, but thinking of it is fair game here
n. hypertrophyc cardiomyopathy, do not present with the kind of pain in presenting in the question...and not a S3, not a murmur, and 37Y/O , hmmm...
u.pneumonia: has a pleuritic chest pain typically, but the question never mentions or describes it...so assume is not this type of chest pain.
v.neumothax: lungs are clear to auscultation.
w. always a big one, but option B is a better guess
gosh, my attending will kill me!!!
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| juanma0
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So the only reason H isnt the answer is because he doesnīt have a CLEAR history of marfan`s? But it is suggested right? I guess this is another typical USMLE BEST ANSWER mind twister.
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| cbenitesch
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Not that typical! Frank! First of all donīt have any of 4 major criteria for Marfan: tall? not enough? ectopia lentis? pectus excavatum? wrist and thumb signs? escolliosys? elbows? lumbosacral extasia? enlarged aortic root? so... in a patient with aortic dissection the location of pain is associated with the location of the dissection. Anterior chest pain with dissections involving the ascending aorta, while (back) pain is associated with descending aortic dissections so he has an extensive dissection?!.... In individuals with a proximal aortic dissection, 36% present with hypertension, while 25% present with hypotension. In those that present with distal aortic dissections, 70% present with hypertension while 4% present with hypotension. but this patien has normal BP!!!... Pulse is suppossed to be low, can find BP differences between arms....
Kind of confusing question
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| frank100
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sorry, never say that marfan is the diagnosis...but the guy is too tall so ONLY thought about it and WROTE it down...not a sin.
but yes, I know how to diagnose Marfanīs also...thank you.
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| cbenitesch
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I meant is not enough support for aortic dissection
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| frank100
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cbenitesch wrote:Clueless... ECG is the gold standar for AMI, whithin 30 minutes pain started. Radiating pain to the left arm and left back can go with AMI. Tearing chest pain goes with aortic dissection, but donīt have BP difference between right and left arm. Aortic Aneurysm usually occurs in Abdominal Aorta. Aortic stenosis, we donīt have any heart murmur. But the guy is too tall and he is 10 kg under his ideal body weight... maybe thatīs the clue. Iīll go with angina or could be pulm embolus
ok, Iīll do it the way you do it (mr cbenitesch), so you can feel how you make people feel when you ost your way...
""""WHATTTT!!!! 10kg under his ideal body weight??? no way man, maybe youīre confused...this guyīs ideal body weight is 90, and his medical recommended weight is 78-130kg, and bmi is 20.9, so in terms of weght and size he is normal. can you post your sources??? I.īm confused...goshhh!!!! of course thatīs not the clue....
And angina??? ohh my, angina of 1 houe duration, no way!!! typical angina is more than 15 seconds and less than 15 minutes...so angina is not the answer....nop!!! """
Iīm not like this, and I respect you alot (mr cbenitesch), because you seem to be a good one, but please lower your anxyety...Iīm trying to help others and help myself in this forum, but I think respect is a good beginig...
thank you
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| cbenitesch
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hehehe... come on man! Iīm not that aggressive! I apologize if I made you feel unconfortable! Iīm here just to learn something new as everybody here!... I guess sometimes is difficult to express in a proper way īcause english is not my native language!... Once again, I apologize because of my anxiety excess!  , and of course I respect you a lot!...
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| cbenitesch
Forum Senior
Topics: 10
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hey frank culd you please post the answer for NBME 3?
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| wyvern
Forum Guru
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His height is a clue to the diagnosis here, and the character of the pain is typical of dissection, i agree with frank
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| King
Forum Senior
Topics: 8
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the key say it is B - Aortic dissection
but what is the diff. from the pathological point of view bet A.dissection & diss.A. aneuryism??
i know that in dissecting A.An.== cystic medial necrosis , HTN
what is the pathology of aortic dissection??!
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| GDS2008
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As far as I know, there is no difference between aortic dissection and dissecting aortic aneurysm. these two terms are synonymous. When an aortic dissection (can be ebacuse of HTN, CMN seen in Marfan's) occurs, another lumen is created within the lamina propria of blood vessels creating a pseudoaneurysm (and therefore the term dissecting aortic aneurysm). So these two things are the same and I believe they wanted to amke H as "aortic aneurysm" (whihc of course is very different from the two). I beleive that this was a mistake. I am sure there will be many here, who would disagree with me, but please have a look at Harrison's, CMDT and other emegency medicine books. Thanks!
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| GDS2008
Forum Elite
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and yes, in case if this was not a mistake -- aortic dissection is a better terminology than dissecting aortic aneurysm.
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| King
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thank u GDS...that was what i wanted to hear.............but the Q is from Usmle cd...they sent it to me ...it is a far possibility to be a mistake
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