Case Study: Chapter 06

Chapter 6: Diseases of the Thoracic Aorta and Aortic Arch



A 74-year-old man presents to the emergency department at 10 PM with complaints of severe chest pain. He has a history of hypertension for which he is on a diuretic, but has no other known cardiovascular disease. He recounts that he was bending over to pick up his shoes when he felt the sudden onset of sharp chest and back pain, which he rated as 9 out of 10 in severity. He denies any associated shortness of breath, but is diaphoretic. On physical exam, his blood pressure is 138/70 and equal in both arms, heart rate is 92, and respiratory rate is 20. His temperature is 37.3° C. His lungs are clear. His cardiac exam is notable only for a I/IV decrescendo diastolic murmur at the left upper sternal border. His jugular venous pressure is 7 cm and his carotid pulses are 2+ bilaterally, without bruits. His peripheral pulses are normal throughout. His abdominal and neurologic exams are unremarkable. His ECG shows normal sinus rhythm, with left atrial enlargement and nonspecific ST-segment and T-wave abnormalities. His chest x-ray is unremarkable. His hematocrit is 39, WBC is 12.5, and creatinine is 1.3.

Case Study: Chapter 6

* 1.) What is the most appropriate imaging study to order?
* 2.) A CTA is obtained and sample axial images, A without contrast and B with contrast, are shown here and on the next page. What do these CT images demonstrate?

* 3.) The patient is treated with intravenous (IV) labetalol in the ED, and his blood pressure falls to 110/68, his heart rate falls to 56, and his pain improves to a 2 out of 10. What would be the appropriate management of the patient at this time?