A 68-year-old man presents to the emergency room with a two-week history of severe cough and shortness of breath, worse when lying flat or bending over. He reports associated headaches, dizziness, lightheadedness, hoarseness of voice, and dysphagia. He has a 20-year history of smoking (one pack per day) and works as an electrician. Vital signs: Temperature: 99 °F Heart rate: 98 beats/min Respiratory rate: 34 breaths/min Blood pressure: 145/95 mm Hg Physical Examination: Swelling of the tongue, face, neck, and upper extremities. Dilated neck veins and collateral veins over the anterior chest wall. Positive Pemberton’s sign (reddish facial tinge with arm elevation). Imaging: Chest X-ray reveals unilateral widening of the superior mediastinum on the right side. Which of the following tests helps to confirm the diagnosis in this patient?
68-year-old man comes to the emergency room reporting severe cough and shortness of breath for the last two weeks. Symptoms get worse when he lies flat or bends over. Review of systems is remarkable for headaches, dizziness, lightheadedness, hoarseness of voice and dysphagia. He works as an electrician. He has a 20 year smoking history, one pack of cigarettes a day. His temperature is 99 ⁰ F, heart rate is 98 beats per minute, respiratory rate is 34 breaths per minute, and blood pressure is 145/95 mm Hg. Physical examination is significant for swelling of tongue, face, neck, and upper extremities. There are dilated neck veins with an increased number of collateral veins covering the anterior chest wall. When you ask the patient to elevate both his arms, you notice a reddish tinge to his facial complexion. Chest x-ray shows widening of the superior mediastinum on the right side. Of the following, which is the most common underlying cause of this syndrome?
68-year-old man comes to the emergency room reporting severe cough and shortness of breath for the last two weeks. Symptoms get worse when he lies flat or bends over. Review of systems is remarkable for headaches, dizziness, lightheadedness, hoarseness of voice and dysphagia. He works as an electrician. He has a 20 year smoking history, one pack of cigarettes a day. His temperature is 99 ⁰ F, heart rate is 98 beats per minute, respiratory rate is 34 breaths per minute, and blood pressure is 145/95 mm Hg. Physical examination is significant for swelling of tongue, face, neck, and upper extremities. There are dilated neck veins with an increased number of collateral veins covering the anterior chest wall. When you ask the patient to elevate both his arms, you notice a reddish tinge to his facial complexion. Chest x-ray shows widening of the superior mediastinum on the right side. Which of the following is the most likely diagnosis in this patient?
A 54-year-old man was brought to the hospital emergency room by deportation officers because he reported severe chest pain and abdominal pain that came suddenly. On further questioning, he has had difficulty eating for the last few weeks; his voice became hoarse; his cough became brassy and his back is hurting a lot. Review of systems is significant for shortness of breath and edema in both feet. He is a migrant from Kenya and his past medical history is significant for a painless genital ulcer on his penis and he was treated for chlamydia and gonorrhea. On physical examination, he is pale, sweating profusely, and hypotensive. Oral examination is shown below. Cardiac pulsations are visible. On auscultation, a soft, high-pitched diastolic decrescendo murmur is best heard in the third intercostal space along the left sternal border at end expiration, with the patient sitting and leaning forward. Chest x-ray is shown below. Gross morphology of the aorta showed contraction of intima, irregular scarring of the media and ‘tree barking’ appearance of the intima. Microscopically, obliteration of the vasa vasorum by intimal changes and scarring is noted. The wall of the vessel has a variably dense plasma cell infiltrate. Of the following, which is the recommended treatment for this condition?
A 54-year-old man was brought to the hospital emergency room by deportation officers because he reported severe chest pain and abdominal pain that came suddenly. On further questioning, he has had difficulty eating for the last few weeks; his voice became hoarse; his cough became brassy and his back is hurting a lot. Review of systems is significant for shortness of breath and edema in both feet. He is a migrant from Kenya and his past medical history is significant for a painless genital ulcer on his penis and he was treated for chlamydia and gonorrhea. On physical examination, he is pale, sweating profusely, and hypotensive. Oral examination is shown below. Cardiac pulsations are visible. On auscultation, a soft, high-pitched diastolic decrescendo murmur is best heard in the third intercostal space along the left sternal border at end expiration, with the patient sitting and leaning forward. Chest x-ray is shown below. Gross morphology of the aorta showed contraction of intima, irregular scarring of the media and ‘tree barking’ appearance of the intima. Microscopically, obliteration of the vasa vasorum by intimal changes and scarring is noted. The wall of the vessel has a variably dense plasma cell infiltrate. Of the following, which is the most likely diagnosis in this patient?
A 42-year-old man with a history of Marfan syndrome presents to the emergency room with severe, sudden, tearing chest pain radiating to the abdomen and back. The pain has progressively shifted downward over the past several hours. He admits to recent cocaine use and has a history of hypertension, previously treated with hydrochlorothiazide, which he stopped due to thunderclap headaches. He also smokes one pack of cigarettes daily. Vital signs: Temperature: 99.8 °F Heart rate: 108 beats/min (right arm); 94 beats/min (left arm) Blood pressure: 198/105 mm Hg (right arm); 170/94 mm Hg (left arm) Respiratory rate: 19 breaths/min Oxygen saturation: 94% on room air Physical Examination: Asymmetric pulses Signs of intravenous drug use (track marks, scarring). Investigations: ECG: Wide QRS complexes Chest X-ray: Widened mediastinum Laboratory findings: Normal troponin and D-dimer levels Which of the following is the next step in the management of this patient?
A 42-year-old man with a history of Marfan syndrome presents to the emergency room with severe, sudden, tearing chest pain radiating to the abdomen and back. The pain has progressively shifted downward over the past several hours. He admits to recent cocaine use and has a history of hypertension, previously treated with hydrochlorothiazide, which he stopped due to thunderclap headaches. He also smokes one pack of cigarettes daily. Vital signs: Temperature: 99.8 °F Heart rate: 108 beats/min (right arm); 94 beats/min (left arm) Blood pressure: 198/105 mm Hg (right arm); 170/94 mm Hg (left arm) Respiratory rate: 19 breaths/min Oxygen saturation: 94% on room air Physical Examination: Asymmetric pulses Signs of intravenous drug use (track marks, scarring). Investigations: ECG: Wide QRS complexes Chest X-ray: Widened mediastinum Laboratory findings: Normal troponin and D-dimer levels Which of the following is a risk factor for aortic dissection in this patient?
A 42-year-old man with a history of Marfan syndrome presents to the emergency room with severe, sudden, tearing chest pain radiating to the abdomen and back. Over the past several hours, the pain has progressively shifted downward. He admits to recent cocaine use and has a history of hypertension, previously treated with hydrochlorothiazide, which he stopped due to thunderclap headaches. He also smokes one pack of cigarettes daily. Vital signs: Temperature: 99.8 °F Heart rate: 108 beats/min (right arm); 94 beats/min (left arm) Blood pressure: 198/105 mm Hg (right arm); 170/94 mm Hg (left arm) Respiratory rate: 19 breaths/min Oxygen saturation: 94% on room air Physical examination reveals: Asymmetric pulses Signs of intravenous drug use (track marks, scarring). Investigations: ECG: Wide QRS complexes Chest X-ray: Widened mediastinum Laboratory findings: Normal troponin and D-dimer levels Most aortic dissections are due to which of the following?
A 42-year-old man with a history of Marfan syndrome presents to the emergency room with severe, sudden, tearing chest pain radiating to the abdomen and back. The pain has progressively shifted downward over the past several hours. He admits to recent cocaine use and has a history of hypertension, previously treated with hydrochlorothiazide, which he discontinued due to thunderclap headaches. He smokes one pack of cigarettes daily. Vital signs: Temperature: 99.8 °F Heart rate: 108 beats/min (right arm); 94 beats/min (left arm) Blood pressure: 198/105 mm Hg (right arm); 170/94 mm Hg (left arm) Respiratory rate: 19 breaths/min Oxygen saturation: 94% on room air On physical examination, the patient has asymmetric pulses and signs of intravenous drug use (track marks, scarring). An electrocardiogram reveals wide QRS complexes, and a chest X-ray shows a widened mediastinum (as shown below). Laboratory findings include normal troponin and D-dimer levels.Which of the following is the most likely diagnosis in this patient?
An 82-year-old woman with a history of coronary artery disease, hypertension, dyslipidemia, and metastatic breast cancer comes to establish care. Her LDL level is 172 mg/dL, but she is unable to perform basic activities of daily living and has been admitted to hospice care with an expected survival of around 6 months. Which of the following is the most appropriate approach to treat her dyslipidemia?