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Program

Emergency Medicine

Training Level

Resident PGY 2

Institution

Henry Ford Macomb

Abstract

Abstract: Keep Your Differential Broad this Back Pain Season, Kyle Diaz D.O., Anthony Colucci D.O. The chief complaint of back pain is a common occurrence in the emergency department. Our departments can often be inundated with this complaint especially now that the season of slips and falls is upon us. We are not only seeing traumatic back pain but chronic back pain and atraumatic acute back pain frequent the halls of the emergency department as well. While wading through the morass of these nonspecific and often menial complaints it may become difficult for a provider to maintain a broad differential. This case will serve as a reminder to remain vigilant while working up back pain. Additionally, information on an interesting diagnosis of aortic ulceration will be gleaned throughout the case review.The case is that of a 65 year old female with significant medical history including hypertension and remote history of smoking who presents to the emergency department complaining of back pain. The patient reports that she has been having mid thoracic back pain for the past 2-3 weeks. This pain is described as aching and is sharp with movement. Patient reports pain radiating to both sides with movement. Patient denies associated chest pain, shortness of breath, nausea, vomiting, neck pain, low back pain, sciatica, incontinence of stool, urinary retention. Patient does report that symptoms improve significantly with leaning forward.A thorough examination demonstrated Para spinal tenderness throughout the mid thoracic spine. Patient’s examination was otherwise normal save her vitals which showed hypertension to the degree of 180/95. Initial evaluation included AP chest, thoracic XR and basic lab work. Pain control was provided as well.On repeat examination patient’s back pain was well controlled however she remained hypertensive and was now having bilateral flank discomfort. At this point advanced imaging was obtained and a CTA of the chest was ordered. This demonstrate a broad based aortic ulceration about the ascending portion of the thoracic aorta.Immediate measures were taken to control patient's elevated blood pressure and consultation was made to vascular surgery. Patient was admitted to the ICU for further management and evaluation. With strict impulse control repeat CTA was ordered at 48 hours. There was no progression of the disease and as such patient was discharged home with conservative medical management as she was not amenable to surgery at time of initial presentation.One month later the patient represented due to continued pain and was found to have a type B thoracic aortic dissection. At this time she underwent TEVAR and after an uncomplicated operation and post-operative course has followed with both family practice and vascular and is progressing well. As a conclusion of the case I would like to discuss the treatment and management of this finding of Aortic ulceration and the morbidity associated with this rare diagnosis. I believe that this interesting case will both add to the expansion of our differential when caring for back pain in addition to providing helpful information for diagnosis that does not have a mass of readily available data.

Publication Date

5-2019

Keep Your Differential Broad This Back Pain Season Penetrating Aortic Ulceration: A Case Report

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