1、Case ReportPRESENT HISTORY:ONSET 40-year old male Transient“electric shock like”back and left shoulder pain Syncope Local hospital PRESENT HISTORY:HOSPITAL 1 Consciousness recovered (one hour after admission)Paroxysmal dull pain in left shoulder and lower back.PRESENT HISTORY：HOSPITAL 1 Neurological
2、 Disorders?Neurological examination was normal.Cerebral computed tomography:normalRadiography:hyperosteogeny lumbar hyperosteogeny?Symptoms relieved:dischargedPRESENT HISTORY：HOSPITAL 2Renal Failure?Chest stiffness&breathlessLower limb edema&oliguria Creatinine:800mmol/LHemodialysis RelievedPRESENT
3、HISTORY：HOSPITAL 3Cardiomyopathy?Endocarditis？Recurred chest stiffness&breathlessECG:nodal tachycardiaUCG:enlarged heart and aorta,hydropericardium.PRESENT HISTORY：COME TO US On January 24th,2012,the patient came to our hospital.PREVIOUS HISTORY Smoking and drinking Ceased smoking and abstained from
4、 alcohol Denied drug abuse Not aware of any hereditary disease in his family.HISTORY：SUMMARYA combination of different clinical findings“Electric shock like”pain(once)Syncope(once)Chest stiffness&BreathlessRepeated low back painPitting edema of lower extremityMonismANALYSIS：PLURALISM Algia：neurologi
5、cal pain？Acute coronary syndrome？Syncope：TIA？Cerebral Infarction？Oliguria&edema：renal failure?Chest stiffness and pain：ACS?PE?ANALYSIS：MONISMGENERAL EXAMINATION Vital Signs BP:Left,104/74mmHg;right,123/77mmHg.water hammer pulse(+)Heart Grade(/6)sighing diastolic murmur at aortic valve area,which rad
6、iates toward the apex.GENERAL EXAMINATION AbdomenMild,non-focal abdominal tendernessLower extremitydiminished left lower extremity pulses.LAB FINDINGSBlood routine WBC 4.74G/L;Hb 129g/L Blood biochemistry Na 145mmol/L,Cl 111 mmol/L,K 4.1mmol/L,Glu 5mmol/L,Urea 5.7mmol/L,Cr 107mol/L,UA 482mol/L;CK 12
7、1IU/L,CK-MB 12.4IU/L,LDH-L 198 IU/L;AMY33 IU/L,LPS 57 IU/L,AFP4.8g/L;Thyroid function T3=1.44nmol/L，T4=102nmol/L，fT3=4.23pmol/L,TSH=3.75mIU/L.LAB FINDINGSCoagulation function PT=18S,INR=1.5,D-Dimer:2.4mg/L(2400g/L,normal:500g/L)ESR:4mm/h.IMAGING FINDINGSIMAGING FINDINGSIMAGING FINDINGSIMAGING FINDIN
8、GSIMAGING FINDINGSCT angiography of chest and abdomen DISCUSSIONDISCUSSION：GENERAL Acute aortic dissection(AAD)Aortic dissection may present with a variety of clinical manifestationsDISCUSSION：GENERAL75%Misdiagnoses include:myocardial infarction cerebral infarctionDISCUSSION：SYMPTOMS&SIGNS Painless:
9、5%Syncope：8%AAD should be considered in the differential diagnosis of syncope,even in the absence of pain.DISCUSSION：SYMPTOMS&SIGNS AAD may mimic an acute coronary syndromeDISCUSSION：SYMPTOMS&SIGNSDISCUSSION：IMAGING Up to now,various non-invasive and invasive diagnostic steps are required to diagnos
10、e or to rule-out AAD in case of clinical suspicion.DISCUSSION：IMAGING CT and MRI of patients with suspected AAD Sensitivity and specificity of CT：reaching 100%Sensitivity of MRI is up to 95-100%DISCUSSION：IMAGING Ultrasonic cardiograms(UCG)TAS(ultrasound of the abdomen)TEE(transesophageal echocardio
11、graphy)DISCUSSION：LAB Determination of D-dimer D-Dimer:2.4mg/L(2400g/L,normal:500g/L)DISCUSSION：TREATMENTMedicationMAP 60 to 75 mmHg target HR：around 60bpmBeta blockers and nitroprusside sodiumCalcium channel blockersDISCUSSION：TREATMENT Interventional therapeutic measures Cardiothoracic SurgeryDISC
12、USSION：CLASSIFICATIONSDISCUSSION：PROGNOSIS The long term follow-up The mortality rate：68%48hrsDISCUSSION：SUMMARY Key in the management of acute aortic dissection is to maintain a high level of suspicion for this diagnosis.DISCUSSION：SUMMARY Rigorous clinical thinking Pertinent examinations Avoid stopgap treatment measures屏蔽泵配件 http:/ 仉睿聪奌
