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Got in Aline, Esmolol, Trauma Consult, and transferred to Jewish
for thoracic surgery.
Vitals: BP: 148/62, HR 66, RR 18, O2 100% T 98.5
Significant Physical Exam –
RRR, no m/r/g, CTAB, abd soft, nt, nd, no bruit, no pulsating mass
RLE strength 4/5, LLE 5/5.
No DP, PT, Popliteal, or Femoral pulse in the right leg.
At this point I was concerned. I excused myself and got the
bedside ultrasound. In my head I wondered was this just a arterial
occlusion, or was this something greater? (Fig. 1-4)
Fig. 7
Fig. 6
Fig. 1
Fig. 2
Diagnosis – Aortic Dissection from the level of the
aortic valve down through
the bifurcation of the iliac
arteries. From the one slice,
you can see he had no flow
to the right leg. CTA demonstrated some collateral
from the gastrics, but overall no flow.
Fig. 3
Fig. 4
Well this is when I started to sweat. I tell the patient what I think
my diagnosis is, and head back to my desk to get orders going. At
this time I review the labs and chest X-ray.
CBC – WNL, CMP – K 3.3, otherwise WNL, UA WNL, Troponin
Neg, Tox Screen Neg,
Coags neg.
Chest Xray - (Fig. 5)
Any more concern?
At this point I ordered
a CTA of the Chest/Abdomen/Pelvis as well as
called the surgery team.
I wanted to get them involved early in the case
the patient deteriorates.
I assessed the patient’s
blood pressure: 130/60
Fig. 5
/ HR 58. I got the nurse
to get the patient to the
CT scanner as well as
discussed with Trauma. At this time pain was controlled with morphine. Trauma evaluated and the CT resulted. (Fig. 6-10)
We now have our diagnosis. When he got back from CT, his blood
pressure was increased to 150/80 and HR 68 with increasing pain.
36
LOUISVILLE MEDICINE
Patient outcome – survived surgery. Otherwise
have not been able to
follow-up past that time. I
shared this case because I
feel it is a great example of
a case where easy bedside
diagnostics can give you/
point you to the diagnosis
early. With the CXR as well
as the bedside ultrasound,
we knew what the patient
had. The CTA was just icing on the cake.
Fig. 8
Fig. 9
Fig. 10
Never be afraid to use the ultrasound. If it had been negative,
this could have gone a completely different direction. Credit to the
psychiatry resident for getting me involved early.
Use the ultrasound. Use it early. Diagnose early. LM
Note: Dr. Shoff is Chief Resident in Emergency Medicine at the
University of Louisville.