"My Chest is Hurting Really Bad"

Adrian Crisan, MD and Chat Dang,MD

July 01, 2003

A 53-year-old female presents to the Emergency Department complaining of acute left substernal chest pain that started more than thirty minutes ago, radiating to her jaw, 8/10 intensity, sharp in quality and is not relieved with two sprays of nitroglycerin. The patient also states she had two episodes of vomiting, some shortness of breath but no associated headache or visual changes. There is a past medical history significant for hypertension, and the patient is using a hypertensive medication prescribed in Mexico.

Vital signs are as follows: T 96.7, RR 13, P 60, BP (LUE 106/54; RUE 67/54).

Physical exam revealed a well-developed woman in moderate distress. There were no signs of JVD, or accessory muscle use. Breath sounds were equal bilaterally with minimal basilar rales, and heart sounds were normal without any associated murmurs. The chest wall was not tender to palpation anteriorly but there was mild tenderness in the mid interscapular region. A radial pulsus parvus was noted in the right upper extremity as compared to the left side. The abdomen was benign and the neurological exam was nonfocal.

Cardiac enzymes were ordered. The EKG revealed a slightly bradycardic sinus rhythm with nonspecific ST/T changes and the portable chest X-ray did not reveal any mediastinal widening. A transthoracic ultrasound was then obtained. Figure AA illustrates the patient’s ascending aorta.

How would you interpret the results of this ultrasound?
How would you manage this case?

ANSWER