1/16. Clinical considerations in the chiropractic management of the patient with marfan syndrome.OBJECTIVE: To describe the chiropractic management of a patient with whiplash-associated disorder and a covert, concomitant dissecting aneurysm of the thoracic aorta caused by marfan syndrome or a related variant. CLINICAL FEATURES: A 25-year-old man was referred by his family physician for chiropractic assessment and treatment of neck injuries received in a motor vehicle accident. After history, physical examination, and plain film radiographic investigation, a diagnosis of whiplash-associated disorder grade I was generated. INTERVENTION AND OUTCOME: The whiplash-associated disorder grade I was treated conservatively. Therapeutic management involved soft-tissue therapy to the suspensory and paraspinal musculature of the upper back and neck. Rotary, manual-style manipulative therapy of the cervical and compressive manipulative therapy of the thoracic spinal column were implemented to maintain range of motion and decrease pain. The patient achieved full recovery within a 3-week treatment period and was discharged from care. One week after discharge, he underwent a routine evaluation by his family physician, where an aortic murmur was identified. Diagnostic ultrasound revealed a dissecting aneurysm measuring 78 mm at the aortic root. Immediate surgical correction was initiated with a polyethylene terephthalate fiber graft. The pathologic report indicated that aortic features were consistent with an old (healed) aortic dissection. There was no evidence of acute dissection. Six month follow-up revealed that surgical repair was successful in arresting further aortic dissection. CONCLUSION: The patient had an old aortic dissection that pre-dated the chiropractic treatment (which included manipulative therapy) for the whiplash-associated disorder. Manipulative therapy, long considered an absolute contraindication for abdominal and aortic aneurysms, did not provoke the progression of the aortic dissection or other negative sequelae. The cause, histology, clinical features, and management considerations in the treatment of this patient's condition(s) are discussed.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
2/16. Clinical case of the month. chest pain, diaphoresis, and dyspnea in a hypertensive 53-year-old man.Aortic dissection is a life-threatening condition requiring urgent diagnosis and treatment. The initial challenge for the physician lies in distinguishing aortic dissection from more common conditions such as myocardial infarction that also are characterized by chest pain. Subsequent management depends on imaging techniques that define whether just the descending aorta is affected or its more proximal portions as well. mortality and morbidity are high, especially when the ascending aorta is involved.- - - - - - - - - - ranking = 0.5keywords = physician (Clic here for more details about this article) |
3/16. A case of pulmonary artery dissection diagnosed in the Emergency Department.pulmonary artery dissections typically occur at the site of a pulmonary artery aneurysm associated with pulmonary hypertension or connective tissue disease. dyspnea on exertion, retrosternal chest pain, central cyanosis, and sudden hemodynamic decompensation are the four main clinical signs and symptoms associated with a pulmonary artery dissection. diagnosis of a pulmonary artery dissection frequently occurs postmortem, as many of these patients experience sudden death when the main pulmonary artery dissects into the pericardium, causing acute cardiac tamponade. pulmonary artery dissection has been diagnosed in living patients using transthoracic echocardiogram, computed tomography (CT) scanning, magnetic resonance imaging (MRI), and angiography. Surgery is curative. Emergency physicians should consider the diagnosis of pulmonary artery dissection in patients presenting with either retrosternal chest pain, dyspnea on exertion, central cyanosis, or sudden hemodynamic decompensation and who have a past medical history of pulmonary hypertension, pulmonary artery surgery, or a disease causing chronic inflammation of myocardial or vascular tissue.- - - - - - - - - - ranking = 0.5keywords = physician (Clic here for more details about this article) |
4/16. cocaine-associated dissection of the thoracic aorta.patients present to emergency departments with a variety of complications related to cocaine abuse. Emergency physicians must be aware of the life- and limb-threatening complications to avoid undue mortality and morbidity. We present the case of a patient with aortic dissection who developed the acute onset of abdominal pain 5 minutes after subcutaneous cocaine use. Four previous reports of cocaine-associated aortic dissection are reported in the literature. These cases and other reports of intra-abdominal vascular injuries related to cocaine use are reviewed. cocaine's mechanism of action as it relates to aortic dissection and some of the pharmacologic agents available for treatment are discussed.- - - - - - - - - - ranking = 0.5keywords = physician (Clic here for more details about this article) |
5/16. Reversal of end-stage renal disease after aortic dissection using renal artery stent: a case report.BACKGROUND: Medical management is the conventional treatment for Stanford Type B aortic dissections as surgery is associated with significant morbidity and mortality. The advent of endovascular interventional techniques has revived interest in treating end-organ complications of Type B aortic dissection. We describe a patient who benefited from endovascular repair of renal artery stenosis caused by a dissection flap, which resulted in reversal of his end-stage renal disease (ESRD). CASE PRESENTATION: A 69 y/o male with a Type B aortic dissection diagnosed two months earlier was found to have a serum creatinine of 15.2 mg/dL (1343.7 micromol/L) on routine visit to his primary care physician. An MRA demonstrated a rightward spiraling aortic dissection flap involving the origins of the celiac artery, superior mesenteric artery, and both renal arteries. The right renal artery arose from the false lumen with lack of blood flow to the right kidney. The left renal artery arose from the true lumen, but an intimal dissection flap appeared to be causing an intermittent stenosis of the left renal artery with compromised blood flow to the left kidney. Endovascular reconstruction with of the left renal artery with stent placement was performed. Hemodialysis was successfully discontinued six weeks after stent placement. CONCLUSION: Percutaneous intervention provides a promising alternative for patients with Type B aortic dissections when medical treatment will not improve the likelihood of meaningful recovery and surgery entails too great a risk. Nephrologists should therefore be aggressive in the workup of ischemic renal failure associated with aortic dissection as percutaneous intervention may reverse the effects of renal failure in this population.- - - - - - - - - - ranking = 0.5keywords = physician (Clic here for more details about this article) |
6/16. Descending necrotising mediastinitis: a report of misdiagnosis as thoracic aortic dissection.Descending necrotising mediastinitis is an uncommon disease in the emergency department. Early recognition is important for a good prognosis for this fatal condition. This report describes a case of a healthy 79 year old woman who was seen in the urgent care centre with the initial presentation of chest pain. Misdiagnosis was made because of the mis-reading of a flap-like artefact over the ascending aorta and difficulty interpreting subtle change of mediastinal soft tissue infiltration. The patient was then treated as dissecting aneurysm over ascending aorta until her condition deteriorated. Although aggressive treatment comprising thoracotomy, cervical incision and drainage, and antibiotics were begun, the response was poor. Emergency physicians should be familiar with this rare but highly lethal disease. Correlation should be made in a patient complaining about chest pain, especially combined with fever, sore throat, dysphagia, or neck swelling.- - - - - - - - - - ranking = 0.5keywords = physician (Clic here for more details about this article) |
7/16. Dissections of the cervicocerebral arteries.We present four cases of cerebral ischemia secondary to dissections of cervicocerebal arteries. The majority of patients presented with transient ischemic attacks and strokes, although one patient presented with headache and focal seizure. In addition to history and physical examination, the diagnostic evaluation of these patients included computed tomography scan, carotid duplex studies, angiogram, and, in some cases, magnetic resonance imaging studies. Initially, the patients were anticoagulated with heparin and then with warfarin for a period of six to eight weeks. The emergency physician must consider such dissections in younger patients with sudden neurologic deficits and no or few risk factors for cerebrovascular disease. In our experience, these are not rare syndromes; with proper workup, prompt diagnosis, and therapy, the prognosis is usually excellent.- - - - - - - - - - ranking = 0.5keywords = physician (Clic here for more details about this article) |
8/16. Traumatic rupture of the thoracic aorta presenting as transient paraplegia.A patient involved in a high-speed motor vehicle accident presented paraplegic to the emergency department. He was noted to have an abnormal chest x-ray and, subsequently, underwent aortography which revealed aortic transection. The patient's paraplegia resolved spontaneously prior to definitive aortic repair hours later. aortic rupture presenting as paraplegia is a rare association, but one an emergency physician should be cognizant of, especially in the case of blunt or decelerating trauma.- - - - - - - - - - ranking = 0.5keywords = physician (Clic here for more details about this article) |
9/16. Abdominal catastrophes.The patient in our case report presented with an acute abdomen but stable vital signs and ABCs. The differential diagnosis initially included most of the entities discussed in this chapter. The ECG ruled out an acute MI. The patient improved with IV hydration and oxygen administration. Abdominal x-ray films ruled out a bowel obstruction, and chest x-ray films ruled out a pulmonic process. Laboratory tests revealed hemoconcentration and leukocytosis. No other laboratory test results were abnormal. While waiting for the surgeon to arrive, the patient remains stable, so the ED physician orders a CT scan of the abdomen. Taking another look at the plain x-ray films, the emergency physician in our case presentation sees a suggestion of free air under the right hemidiaphragm above the liver on the CXR and between the liver and the right abdominal wall on the decubitus ABD x-ray. The CT scan confirms the presence of free air within the peritoneal cavity, and the patient is taken to surgery for an exploratory laparotomy. The final diagnosis is perforated peptic ulcer. With hindsight, the patient and wife recall a previous diagnosis of a possible ulcer in the past.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
10/16. Cardiac surgical emergencies.Cardiac surgical emergencies are broken down into three categories: cardiac trauma, aortic dissection, and surgery for acute myocardial infarctions. Emphasis is given to describing the presentation of patients with such problems, and to the salient aspects of the clinical strategies for managing each problem. An important goal of each section is focusing the critical care physician on the early recognition of cardiac surgical emergencies and providing him with some rationale for instituting an expeditious plan of therapy.- - - - - - - - - - ranking = 0.5keywords = physician (Clic here for more details about this article) |
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