An 80-year-old man is brought to the hospital due to increasing chest pain. Over the past 6 weeks, he has had dry cough, dysphagia, and a change in voice quality. The patient has a long history of hypertension. He is an ex-smoker with a 35-pack-year history. On physical examination, the patient appears anxious, pale, and diaphoretic. Blood pressure is 80/60 mm Hg, pulse is 120/min, and respirations are 20/min. While being evaluated in the emergency department, he develops cardiac arrest with pulseless electrical activity and cannot be resuscitated. Autopsy is most likely to show which of the following findings?

Question

An 80-year-old man is brought to the hospital due to increasing chest pain.  Over the past 6 weeks, he has had dry cough, dysphagia, and a change in voice quality.  The patient has a long history of hypertension.  He is an ex-smoker with a 35-pack-year history.  On physical examination, the patient appears anxious, pale, and diaphoretic.  Blood pressure is 80/60 mm Hg, pulse is 120/min, and respirations are 20/min.  While being evaluated in the emergency department, he develops cardiac arrest with pulseless electrical activity and cannot be resuscitated.  Autopsy is most likely to show which of the following findings?

Quizplus · Accepted Answer

11ec160b_38b2_4118_9249_0122de852a29_MD0001_00 Thoracic aortic aneurysm (TAA) can involve the ascending or descending aorta above the diaphragm. It is usually asymptomatic until it grows large enough to encroach on nearby structures or cause rupture. This patient likely experienced progressive TAA expansion with symptomatic compression of surrounding structures, followed by acute rupture that led to shock and cardiac arrest. TAA usually results from age-related degenerative changes in the medial layer of the aorta; these changes are likely accelerated by risk factors, including dyslipidemia, hypertension, tobacco use, and family history. Connective tissue diseases such as Marfan or Ehlers-Danlos syndrome also increase the risk. The most common symptomatic presentation of TAA is pain, which is typically localized to the chest and back. If the TAA impinges upon the esophagus, it can also cause dysphagia. Similarly, compression of the left recurrent laryngeal nerve or left vagus nerve results in hoarseness, whereas compression of the phrenic nerve can cause hemidiaphragmatic paralysis. Respiratory manifestations, including wheeze, cough, hemoptysis, and dyspnea may occur due to tracheobronchial obstruction. Other complications include heart failure due to aortic valve regurgitation and superior vena cava syndrome from venous compression and occlusion. Chest x-ray may suggest the diagnosis of TAA, demonstrating a widened mediastinum, enlarged aortic knob, and tracheal deviation. (Choice A) Pulmonary fat embolism most commonly results in acute dyspnea, tachypnea, and hypoxemia. Patients commonly develop neurologic abnormalities and a petechial rash, both of which this patient lacks. (Choice B) Ventricular free-wall rupture is a life-threatening complication of ST elevation myocardial infarction that typically occurs 5 days to 2 weeks after the event. It can also result in shock and cardiac arrest, but it would not explain this patient's subacute cough, voice change, or dysphagia. (Choice C) Patients with a Mallory-Weiss tear have hematemesis and epigastric or back pain. These esophageal tears are usually preceded by episodes of nonbloody vomiting or retching. (Choice D) Spontaneous pneumothorax results from the rupture of a pulmonary bleb and can occur with or without a preceding history of lung disease. Most patients describe acute chest pain and dyspnea. Although it can rarely progress to a tension pneumothorax with obstructive shock, such a condition would not explain this patient's subacute symptoms. Educational objective: Thoracic aortic aneurysms are usually asymptomatic until they grow large enough to compress surrounding structures or cause rupture. The most common symptomatic presentation is chest or back pain, but compression of nearby structures can cause dysphagia, hoarseness, cough, or dyspnea. __________ References: Thoracic aortic aneurysm: reading the enemy's playbook. (http://www.ncbi.nlm.nih.gov/pubmed/18439439) Management of acute aortic dissection and thoracic aortic rupture. (http://www.ncbi.nlm.nih.gov/pubmed/29507729)

An 80-Year-Old Man Is Brought to the Hospital Due to Increasing