Could any two cases be any more dissimilar in terms of severity? I had these two on my last shift shortly after one another.
Case 1. A 75 year old man with no medical history, on no meds but a heavy smoker presents with sudden onset chest pain followed by severe right arm pain and loss of sensation in the hand. He was also “sweaty”. His chest pain was gone spontaneously after about 20 minutes but the hand felt “heavy” and was “cold”. On exam, he has no pulses or doppler signals in the brachial, radial, and ulnar arteries – although there is a good axillary pulse. The hand is cool and slightly pale with capillary refill about 5 seconds . He also has mild weakness in that arm – which he thinks is because it “hurts like hell”. He has both a loud systolic AND diastolic murmur. EKG nonspecific changes and CXR normal.
Diagnosis?
Type A Aortic Dissection involving his left carotid artery (stroke symptoms), and right subclavian artery (extending down to the mid upper arm causing the loss of pulses in the elbow and lower but preserving the axillary pulse) and going all the way down to the iliacs with involvement of the left renal artery as well. His aortic valve appeared to be involved as well (hence the diastolic murmur). Turns out he had “aberrant” anatomy of his major vessels causing this strange presentation. I give credit to the cardiologist for convincing me to order the CT even though it initially sounded like an isolated arterial occlusion of the brachial artery (which in retrospect is exceedingly rare). We could not get him to the OR fast enough. That case took up my whole first 1.5 hours of my shift.
Case 2. A 4 year old boy is brought in by his very anxious mother demanding immediate evaluation of the boy. He accidentally pricked his middle finger with a clean and unused finger lancet used for monitoring a diabetic’s blood sugar. Even though it belonged to his Grandmother, the Mother was terrified that maybe it was “dirty” and that his finger might suffer irreparable harm.
Diagnosis?
Superficial laceration of the finger tip. BFD. Total waste of time. We could not get them out of the ER fast enough.
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