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Answers on p 808.
A 53 year old man presented with a four hour history of epigastric and lower chest pain radiating to the back and associated with vomiting, sweating, and breathlessness. He smoked six cigarettes a day. Examination showed him to be distressed. There was a significant discrepancy in the blood pressure between the two arms. The left carotid, brachial, and radial pulses were not palpable. The abdomen was soft and non-tender. An ECG was unremarkable, as was the chestx ray. Computed tomography of the chest is shown (fig 1). Emergency surgery was carried out, from which he made a good recovery and was discharged home 10 days later.
A 66 year old man was admitted with a three hour history of severe chest pain radiating to the back. He had had an abdominal aneurysm repaired two years ago. He smoked 10 cigarettes a day. Clinically he was found to be cold and clammy, with a high blood pressure in both arms. He was in sinus rhythm. There was a soft systolic murmur heard over the precordium, but the lungs were clear. ECG showed a left bundle branch block. Chest x ray showed a large heart, with unfolding of the thoracic aorta. In view of theses findings and bearing in mind his past history, computed tomography of the chest was undertaken (fig 2). He was transferred to intensive care for further management and was discharged home two weeks later.
- What is your diagnosis in both the cases?
- What investigations would you order to obtain a correct diagnosis?
- How are the two cases managed in clinical practice?