q12.87 - sami2004

[ArchivalUser]

A 62-year-old man is evaluated because of the sudden onset of severe substernal chest pain that radiates to his neck and back and has persisted for 45 minutes. He has a 20-year history of hypertension and a 60-pack-year smoking history but has no prior history of myocardial infarction or congestive heart failure. Physical examination shows an anxious, diaphoretic man. His pulse rate is 96/min and regular, respiratory rate is 24/min, and blood pressure is 160/90 mm Hg in his right arm. His lungs are clear to percussion and auscultation. Cardiac examination shows a normal S1, a loud A2, and an S4. The electrocardiogram shows left ventricular hypertrophy with abnormal repolarization. A chest radiograph reveals mediastinal widening, mild cardiomegaly, and clear lung fields.

Which of the following is the most appropriate initial management?

(A) Begin thrombolytic therapy.

(B) Request emergency coronary angiography.

© Request transesophageal echocardiography.

(D) Await serum troponin results.

(E) Begin intravenous heparin.

[ArchivalUser]

ccc?

[ArchivalUser]

© Request transesophageal echocardiography.

[ArchivalUser]

C,
Dissecting aneurysm.
TEE, CT with contrast and MRA are used to confirm.
TEE for critically ill patients who cant move.

[ArchivalUser]

''

[ArchivalUser]

Sure for C

[ArchivalUser]

answer is c

Although chest pain in a 62-year-old man most often is due to an acute coronary syndrome, the nondiagnostic electrocardiogram and the mediastinal widening on the chest radiograph raise the possibility of aortic dissection, especially because the patient has a clinical history of hypertension. Rapid exclusion (or diagnosis) of aortic dissection is essential. Transesophageal echocardiography has a high sensitivity and specificity for aortic dissection and can be performed rapidly at the patient’s bedside. Therapy with a b-blocker to decrease blood pressure and heart rate should be initiated immediately and continued during the transesophageal examination. If an ascending aortic dissection is present, prompt surgical intervention is indicated; therefore, it is inappropriate to wait for cardiac enzyme results. In addition, cardiac enzyme values may be positive with a dissection if the intimal flap involves one of the coronary ostia. Both thrombolytic therapy and heparin are contraindicated to prevent further bleeding or rupture if a dissection is present. If the patient is taken emergently to the catheterization laboratory, aortic root angiography should be performed prior to coronary angiography