Question

A 55-year-old man presents with severe central chest pain. He is a farmer and describes the pain as tearing, saying it started suddenly and is radiating. He is only able to lie comfortably on his side. He denies any previous symptoms. He feels nauseous but has not vomited. He has no major illnesses and knows of none that run in his family. He does not use alcohol, tobacco, or illicit substances. He is allergic to sulfa drugs.

On physical exam he appears to be in extreme pain, despite lying on his side. His temperature is 37.0°C, heart rate is 110 BPM, blood pressure is 180/105 mm Hg, and his respiratory rate is 20/min. Cardiac exam reveals normal S1 and S2 without rubs or gallop. The top of his internal jugular venous column is present at 2 to 3 cm above the sternal notch. Chest auscultation reveals no abnormalities. He has normal active bowel sounds tympanic to percussion. Extremity exam was normal and the lower motor and sensory function is intact.

ECG shows left ventricular hypertrophy and chest X-ray shows widened mediastinum. Labs show:

Hemoglobin 13.5 g/dL
Leukocyte count 5,000 cells/dL
Platelet count 190.000 cells/mL
Urea 70 mg/dL
Creatinine 2.5 mg/dL
Sodium 139 mmol/dL
Potassium 4.8 mmol/dL
Calcium 8.9 mg/dL
Bicarbonate 30 mEq/L
Troponin T <0.03
Creatinine Kinase 150 IU

What is the best test for diagnosing this patient's condition?

1 CT angiography
2 Magnetic resonance angiography (MRA)
3 Transesophageal echocardiography
4 Troponin
5 Chest X-ray

Answer 1

CT angiography is the best diagnostic test for the 55-year-old man with symptoms suggestive of aortic dissection, including severe, radiating chest pain and a widened mediastinum on chest X-ray.

Step-by-step explanation:

The best test for diagnosing the condition of a 55-year-old man with severe central chest pain, described as tearing and radiating, is CT angiography.

The patient's symptoms, along with findings from the physical exam, ECG showing left ventricular hypertrophy, and chest X-ray showing widened mediastinum, suggest a possible aortic dissection.

CT angiography is an excellent diagnostic tool for visualizing the aorta and determining if an aortic dissection is present. Magnetic resonance angiography (MRA) is also an option, but it is not as readily available and takes longer to perform.

Transesophageal echocardiography is less suited for the initial diagnosis but could be used for further evaluation. Troponin levels are used to diagnose myocardial infarction (MI), which is less likely in this patient given the symptom description and ECG findings.

The chest X-ray has already been performed and has assisted in raising suspicions of an aortic dissection due to a widened mediastinum.