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Case ReportCase ReportPRESENT HISTORY:ONSET40-year old maleTransient“electric shock like”back and left shoulder painSyncopeLocal hospital Present history:Onset40-yearPRESENT HISTORY:HOSPITAL 1Consciousness recovered (one hour after admission)Paroxysmal dull pain in left shoulder and lower back.Present history:hospital 1CoPRESENT HISTORY：HOSPITAL 1 Neurological Disorders?Neurological examination was normal.Cerebral computed tomography:normalRadiography:hyperosteogeny lumbar hyperosteogeny?Symptoms relieved:dischargedPresent history：hospital 1 NePRESENT HISTORY：HOSPITAL 2Renal Failure?Chest stiffness&breathlessLower limb edema&oliguria Creatinine:800mmol/LHemodialysis RelievedPresent history：hospital 2RenaPRESENT HISTORY：HOSPITAL 3Cardiomyopathy?Endocarditis？Recurred chest stiffness&breathlessECG:nodal tachycardiaUCG:enlarged heart and aorta,hydropericardium.？Present history：hospital 3CardPRESENT HISTORY：COME TO USOn January 24th,2012,the patient came to our hospital.Present history：come to usOn JPREVIOUS HISTORYSmoking and drinking Ceased smoking and abstained from alcoholDenied drug abuseNot aware of any hereditary disease in his family.previous historySmoking and HISTORY：SUMMARYA combination of different clinical findings“Electric shock like”pain(once)Syncope(once)Chest stiffness&BreathlessRepeated low back painPitting edema of lower extremityMonismhistory：summaryA combinatiANALYSIS：PLURALISMAlgia：neurological pain？Acute coronary syndrome？Syncope：TIA？Cerebral Infarction？Oliguria&edema：renal failure?Chest stiffness and pain：ACS?PE?Fractured Fractured&confusedconfusedAnalysis：pluralismAlgia：neurolANALYSIS：MONISM？Analysis：monism？GENERAL EXAMINATION Vital Signs BP:Left,104/74mmHg;right,123/77mmHg.water hammer pulse(+)Heart Grade(/6)sighing diastolic murmur at aortic valve area,which radiates toward the apex.General examination Vital SignGENERAL EXAMINATION AbdomenMild,non-focal abdominal tendernessLower extremitydiminished left lower extremity pulses.General examination AbdomenLAB 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 121IU/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 FINDINGSBlood routineOtherLAB FINDINGSCoagulation function PT=18S,INR=1.5,D-Dimer:2.4mg/L(2400g/L,normal:500g/L)ESR:4mm/h.LAB FINDINGSCoagulation functiIMAGING FINDINGSImaging findingsIMAGING FINDINGSImaging findingsIMAGING FINDINGSImaging findingsIMAGING FINDINGSImaging findingsIMAGING FINDINGSCT angiography of chest and abdomen Imaging findingsCT angiographyDISCUSSIONdiscussionDISCUSSION：GENERALAcute aortic dissection(AAD)Aortic dissection may present with a variety of clinical manifestationsDiscussion：generalAcute aorticDISCUSSION：GENERAL75%Misdiagnoses include:myocardial infarction cerebral infarctionDiscussion：general75%DISCUSSION：SYMPTOMS&SIGNSPainless:5%Syncope：8%AAD should be considered in the differential diagnosis of syncope,even in the absence of pain.Discussion：symptoms&signsPaiDISCUSSION：SYMPTOMS&SIGNSAAD may mimic an acute coronary syndromeDISCUSSION：symptoms&signsAADDISCUSSION：SYMPTOMS&SIGNSDISCUSSION：symptoms&signsDISCUSSION：IMAGINGUp to now,various non-invasive and invasive diagnostic steps are required to diagnose or to rule-out AAD in case of clinical suspicion.DISCUSSION：IMAGINGUp to now,vDISCUSSION：IMAGINGCT and MRI of patients with suspected AAD Sensitivity and specificity of CT：reaching 100%Sensitivity of MRI is up to 95-100%DISCUSSION：IMAGINGCT and MRI oDISCUSSION：IMAGINGUltrasonic cardiograms(UCG)TAS(ultrasound of the abdomen)TEE(transesophageal echocardiography)DISCUSSION：imagingUltrasonic cDISCUSSION：LABDetermination of D-dimerD-Dimer:2.4mg/L(2400g/L,normal:500g/L)DISCUSSION：labDetermination ofDISCUSSION：TREATMENTMedicationMAP 60 to 75 mmHg target HR：around 60bpmBeta blockers and nitroprusside sodiumCalcium channel blockersDiscussion：TreatmentMedicationDISCUSSION：TREATMENTInterventional therapeutic measuresCardiothoracic SurgeryDiscussion：TREATMENTInterventiDISCUSSION：CLASSIFICATIONSDISCUSSION：CLASSIFICATIONSDISCUSSION：PROGNOSISThe long term follow-upThe mortality rate：68%48hrsDiscussion：PrognosisThe long tDISCUSSION：SUMMARYKey in the management of acute aortic dissection is to maintain a high level of suspicion for this diagnosis.Discussion：SummaryKey in the mDISCUSSION：SUMMARYRigorous clinical thinkingPertinent examinationsAvoid stopgap treatment measuresDiscussion：SummaryRigorous cliThank youThank you！Thank you！屏蔽泵配件 http:/ 仉睿聪奌屏蔽泵配件 http:/www.pingbibeng.
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