Resident Chang Kung Memorial Hospital Kaohsiung, Kaohsiung, Taiwan (Republic of China)
Chief Complaint : Acute onset right flank while lying on bed
History of Present Illness : This 46 year old male, who denied systemic disease, presented to our emergency department due to sudden onset right flank pain while lying on his bed. Initial vital signs in the right arm was 143/72 mm of Hg, pulse rate was 73 beats per minute, and her respiratory rate was 18 per minute and temperature was 36 degrees celsius. Accompanied symptoms include soreness and numbness from right thigh extending to lower leg and patient complain difficulty moving his leg. Pain score was around VAS:6 accompanied with cold sweating. According to patient, his occupation involved heavy lifting. He denied chest pain, dyspnea, fever, hematuria or abdominal pain.
Pertinent Physical Exam: Physical examination reveal right lower leg muscle power decrease (muscle power 4), SLRT test negative. Bilateral legs looked pale. Right legs were cold to the touch compared with left leg. No tenderness, erythema or swelling was noted. Respiratory and abdomen examinations were normal.
Pertinent Laboratory Data: A T+L spine radiography was ordered with L spine spurs formation but otherwise negative finding for spondylolisthesis or compression fracture. Bedside echo was done, which showed poor femoral artery perfusion on doppler. Urine analysis showed hematuria without significant increase of white count. CTA of aorta was arranged preceding negative findings from initial evaluation, which showed Stanford type A aortic dissection with intimal flap extending to aortic root, bilateral common iliac arteries, innominate artery and left CCA, right external iliac artery from false lumen with thrombosis.
Case Discussion: This case is an great example of why aortic dissection is called the “great masquerader”. Although there there is nothing new about the disease, the prompt recognition of the situation has always been an import task in the emergency department, owing to the high mortality rate without early surgical intervention. In this case, relative stable vital signs , initial presentations without typical chest pain and history of heavy weight lifting may lead doctors into approaching the case as a probable spinal stenosis, siatica or even urolethiasis due to findings of hematuria. However, when physical examinations such as pale leg and pain characteristics such as numbness and paralysis indicate a possibility of a ischemic limb, physicians should reconsider if this symptoms can be fully explained by initial differential diagnosis.
Several radiological tests can aid in diagnosis including, mediastinal widening on CXR, contrast CT, TEE or MRA but none are as readily available as POCUS. According to previous studies, early POCUS use can help reduce diagnosis time of up to 145 minutes if performed early. Moreover POCUS not only aid diagnosis but also help with resuscitation by assessing intravascular volumes.
References and Acknowledgements (Optional): 1.The diagnosis of aortic dissection by emergency medicine ultrasound. Fojtik JP, Costantino TG, Dean AJ. J Emerg Med. 2007;32:191–196 2.Emergency physician focused cardiac ultrasound improves diagnosis of ascending aortic dissection. Pare JR, Liu R, Moore CL, Sherban T, Kelleher MS Jr, Thomas S, Taylor RA. Am J Emerg Med. 2016;34:486–492
