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You are evaluating a 17-year-old boy who is new to the area and has not been receiving regular medical care. His chief complaint is a sharp sudden onset ripping sensation in his chest that developed while he was swimming laps. He got out of the pool and the chest pain rapidly worsened. His exam is significant for clear lung sounds, no reproducible chest pain with palpation, no cardiac murmur, and tachycardia with a right radial pulse that feels weaker than the left. You also notice that he is particularly tall, with long fingers.
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August 5, 2025 at 8:09 pm
E) Chest CT angiogram
The patient is exhibiting physical characteristics of Marfan syndrome, which, along with other connective tissue diseases such as Ehlers-Danlos syndrome, puts him at risk for acute aortic dissection. The classic triad for aortic dissection is sudden onset chest or back pain with a ripping or tearing sensation, pulse and blood pressure discrepancies between limbs and deficits, and mediastinal widening on CXR. Patients may have neurologic deficits, hypotension, and syncope. If the dissection propagates proximally to affect the aortic valve, a murmur of aortic regurgitation may be present. Chest CT angiography is definitively diagnostic. Transesophageal echocardiography may be used for diagnosis in patients too unstable to go to the CT scanner but requires experienced operators and procedural sedation. If the dissection has compromised blood flow there may be signs of ischemia on ECG and an elevated troponin, but this is not diagnostic. D-dimer is also a marker for aortic dissection, and D-dimer < 500 ng/mL has strong negative predictive value, but D-dimer is not diagnostic. CXR often shows a widened mediastinum but is also not considered diagnostic.