kpmle2
Forum Elite
Topics: 29
Posts: 292
|
A 29-year-old woman in the 28th week of pregnancy has sudden onset of severe anterior chest pain radiating to her back. The pain began 2 hours earlier and increased in severity. It was not associated with shortness of breath, nausea or vomiting, or diaphoresis. The patient has a history of mitral valve prolapse that was diagnosed on echocardiogram 10 years earlier. Her only medication is a prenatal vitamin. Her family history is unremarkable.
On physical examination, blood pressure is 105/78 mm Hg, heart rate is 110/min, and respiration rate is 18/min while the patient is lying still. The patient is afebrile. Examination of the head, eyes, ears, nose, and throat shows a high, arched palate. Carotid pulses are normal bilaterally, with no jugular venous distension. The lungs are clear to auscultation. Cardiac examination shows a nondisplaced apical impulse, diminished S1, physiologically split , and a soft blowing murmur in early diastole along the right sternal border. A midsystolic click and a late systolic murmur are noted. Abdominal examination shows a gravid uterus that is appropriate for gestational age. Trace pedal edema and intact symmetrical pulses are noted throughout. Fetal heart sounds are normal. An electrocardiogram shows mild T-wave flattening.
Laboratory findings
hematocrit of 32% and platelet count of 170,000/μL.
Fetal monitoring is instituted, and morphine is administered for pain control.
Which of the following is the most appropriate diagnostic test?
A. Serum troponin measurement
B. Transthoracic echocardiogram
C. Magnetic resonance angiography
D. Transesophageal echocardiography
E. Helical computed tomography scan
|
| Aashi
Forum Moderator
Topics: 112
Posts: 984
|
Marfan syndrome, Could be an aortic dissection-------->TEE is the dx test of choice------>D
___________________
"Obstacles are those frightful things you see when you take your EYES off your goal."
|
| neuroblastoma
Forum Guru
Topics: 99
Posts: 1,016
|
D. Transesophageal echocardiography
|
| Vietnamese
Forum Elite
Topics: 12
Posts: 285
|
D- High sensitive and specific
___________________
Nothing is impossible.
|
| tamerbashir
Forum Elite
Topics: 20
Posts: 284
|
D
|
| drduck
Forum Guru
Topics: 82
Posts: 529
|
D...
|
| cool doctor
Forum Junior
Topics: 1
Posts: 226
|
she is stable
I will choose C , if she wasnt it will be D
|
| Ivonne
Forum Guru
Topics: 55
Posts: 1,450
|
Nice detail for Marfan: arched palate and MVP
Aortic dissection with normal blood pressure(We don't know BP in other arm) but stll normal BP doesn't exclude AD
Will go with D
___________________
If you beleive you can do it then you WILL DO IT!! (by Mymeghhi)
|
| kpmle2
Forum Elite
Topics: 29
Posts: 292
|
The correct answer is D
Recognize an acute aortic dissection.
This patient has no evidence of myocardial ischemia. The most likely diagnosis is acute dissection of the ascending aorta. This patients previous diagnosis of mitral valve prolapse raises the question of a connective tissue disorder, such as Marfan syndrome. A negative family history does not exclude the diagnosis because more than half of cases are sporadic. A diastolic murmur in a patient who has chest pain is highly suggestive of ascending aortic dissection, and this life-threatening diagnosis must be excluded. In rare cases, a pregnant woman has a myocardial infarction as a result of spontaneous coronary dissection or acute intracoronary thrombosis. In this case, the normal finding on electrocardiogram makes this diagnosis unlikely. Further testing should not be delayed pending measurement of the troponin level. A transthoracic echocardiogram is likely to show mitral valve prolapse and mitral regurgitation. Aortic insufficiency is likely to cause dilation of the aortic root. However, the sensitivity of this test for detecting aortic dissection is only approximately 65%. Given the potential gravity of waiting because of the high mortality rate in the first 24 hours, a more accurate test is preferred. Magnetic resonance angiography is usually a good choice for diagnosing aortic dissection, which is the most likely diagnosis in this patient. This test is considered safe for the fetus; no harmful effects have been attributed to magnetic resonance imaging. However, it is difficult to monitor the patient in the magnet, and this patient’s aortic insufficiency and severe chest pain warrant rapid diagnosis and close monitoring. Although helical computed tomography scanning is rapid and accurate, it is best to avoid radiation to the fetus.
With transesophageal echocardiography, the patient can safely be sedated with midazolam and fentanyl, β-blockers can be administered, and the diagnosis can be confirmed and the site of aortic dissection identified within minutes of esophageal intubation. The information that is obtained is usually adequate for surgical intervention, and surgery rarely needs to be delayed for confirmatory studies. One exception is suspected involvement of the great vessels.
Preeclampsia does not cause chest pain. The patient is not hypertensive. Occasionally, chest pain occurs in patients who have hemolytic anemia, abnormal liver function, and low platelet count (HELLP syndrome). However, this syndrome usually occurs in the third trimester and is associated with a platelet count <100,000/μL.
|
|
| |
| | | | | | | | | |
