WBR0838

Author	PageAuthor::Neeraja Danda M.B.B.S
Exam Type	ExamType::USMLE Step 2 CK
Main Category	MainCategory::Internal medicine
Sub Category	SubCategory::Cardiovascular
Prompt	[[Prompt::A 48 year old male patient presents to the emergency department with the sudden onset of severe chest pain. He describes the pain as radiating to the upper back between the scapulae. Blood pressure is 170/110. He has a history of hypertension for the last 10 years and has smoked a pack of cigarettes a day for 10 years. What is the most appropriate initial step in the management of this patient?]]
Answer A	AnswerA::Chest X ray
Answer A Explanation	[[AnswerAExp::Incorrect Chest X-ray is one of the important initial diagnostic tools in aortic dissection which shows widened mediastinum. However, we suggest pharmacotherapy be initiated before confirming the diagnosis as aortic dissection is an emergency which could be fatal if left untreated too long.]]
Answer B	AnswerB::CT angiogram
Answer B Explanation	AnswerBExp::'''Incorrect''' It is the most accurate diagnostic test for aortic dissection, but not the most appropriate initial step.
Answer C	AnswerC::Beta blockers
Answer C Explanation	AnswerCExp::Beta blockers are the initial drug of choice in aortic dissection.
Answer D	AnswerD::Nitroprusside
Answer D Explanation	[[AnswerDExp::Incorrect Though nitroprusside is also used to decrease the high blood pressure in aortic dissection it should be given after beta blockers. Nitroprusside administration may lead to reflex tachycardia which will increase the tearing force in the aorta.]]
Answer E	AnswerE::Surgery
Answer E Explanation	AnswerEExp::'''Incorrect''' Surgery is the definitive treatment in aortic dissection, but reducing the blood pressure first is the most appropriate first step
Right Answer	RightAnswer::C
Explanation	[[Explanation::The type of pain with sudden onset and characteristic radiation to the back between the scapulae with high blood pressure in a hypertensive patient with smoking history hints strongly towards Aortic dissection. The most important initial task is to reduce the arterial blood pressure which could worsen the tear in the aorta. During aortic dissection, a false lumen is created, often by mechanical stress or compromised integrity of the arterial wall, as in Marfan’s syndrome. Beta blockers are always the initial drug of choice to reduce the force causing the tear in the aorta. Educational Objective: Beta blockers are the initial drug of choice in aortic dissection to decrease the tearing force in the aorta and thus prevent further dissection of the aorta. References: Page 70 master the boards Step 3 2009, Page 104 Master the boards Step 2 CK second edition Educational Objective: References: ]]
Approved	Approved::Yes
Keyword	WBRKeyword::Aortic dissection, WBRKeyword::Beta blockers
Linked Question	Linked::
Order in Linked Questions	LinkedOrder::