Case1.
S:
48 y/M, slim and tall, 保全人員, complain of acute onset chest tightness and pain, with cold sweating 30 mins ago when he was making a phone call. He could not discribed the characteristic of pain specifically, only with some ‘tightness’ instead of ‘compressed’ adjuctives. There was no ratiation pain, and no other nausea/vomiting sensation.
O:
Heart: no murmur, RHB, Chest: clear breathing sound.
Vital sign: relative normal stable. (no BP down, no increased HR 80bpm)
EKG: revealed bigeminal VPC.
Past History: arrhythmia, unknown
Impressive of ACS first, MONA was prescribe, however, after 15 mins, symptom persist…then the next?
WE TRANSFER PT TO 急救間. On monitor…
郭V接著問我們應該做什麼？
Recheck: vital sign 仍然stable…
個人認為重新PE, recheck chest, heart sound. Four limbs BP. 重follow EKG
接著當然建議cardiac sono. （if heart sound with murmur finding…）
主要是想跟aorta dissection 做區別。
後來sono就發現其實已經有aortic root dilatation, with moderate AR. Confirmed classic type A aortic dissection, 後續治療…（當然就是aortic dissection才要進一步討論的）
Take Home Message
- 當用MONA治療後，病人症狀沒有緩解，EKG也沒有進一步ischemia finding, 仍然要考慮其他的ddx…
- Aortic Dissection確診後，要趕忙停止nitroglycerin以及ASA, Plavix…
- 有些Aortic Dissection在Aortic Arch以上時，也可能以stroke來表現。這個ddx就更困難了…
- 歡迎討論
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