ABSTRACT
A 62-year-old man presented to the Emergency Department with dyspnoea and central pleuritic chest pain radiating posteriorly to between the scapulae. His medical history included hypertension, osteoporosis and chronic kidney disease secondary to focal segmental glomerulosclerosis with relapsing nephrotic syndrome. Significant examination findings included a loud palpable P2 and a displaced apex beat. An ECG revealed sinus tachycardia with a right-bundle branch block and p-pulmonale. A CT pulmonary angiogram and aortogram demonstrated extensive bilateral pulmonary emboli and a descending thoracic aortic dissection. Subsequent ultrasound of the lower limbs confirmed an extensive, non-occlusive deep vein thrombosis in the right calf. Management of this patient involved therapeutic anticoagulation and tight blood pressure control, with plans for surgical repair delayed due to worsening renal impairment and subsequent supratherapeutic anticoagulation. Co-existence of an aortic dissection and PE has been rarely described and optimal management remains unclear.
Subject(s)
Aortic Dissection/therapy , Glomerulosclerosis, Focal Segmental/complications , Nephrotic Syndrome/complications , Pulmonary Embolism/therapy , Venous Thrombosis/therapy , Aortic Dissection/etiology , Anticoagulants/therapeutic use , Antihypertensive Agents/therapeutic use , Humans , Hypertension/etiology , Male , Middle Aged , Osteoporosis/etiology , Pulmonary Embolism/etiology , Renal Insufficiency, Chronic/etiology , Risk Factors , Venous Thrombosis/etiologySubject(s)
Diatrizoate Meglumine/administration & dosage , Endometriosis/complications , Intestinal Obstruction , Intestine, Small , Aged, 80 and over , Conservative Treatment/methods , Contrast Media/administration & dosage , Endometriosis/surgery , Female , Humans , Hysterectomy/methods , Intestinal Obstruction/diagnosis , Intestinal Obstruction/etiology , Intestinal Obstruction/physiopathology , Intestinal Obstruction/therapy , Intestine, Small/diagnostic imaging , Intestine, Small/pathology , Intubation, Gastrointestinal/methods , Multimorbidity , Ovariectomy/methods , Radiography, Abdominal/methods , Tomography, X-Ray Computed/methods , Treatment OutcomeABSTRACT
BACKGROUND: Low back pain is responsible for significant personal and societal burden, particularly when it becomes persistent. Despite international consensus regarding the judicious use of diagnostic spinal imaging, patients continue to be over-referred. OBJECTIVE: The aim of this article is to highlight the critical need for primary care clinicians to engage in thoughtful use of imaging procedures, and to consider alternative or adjunct methods for providing reassurance, in order to avoid or mitigate the potential negative impact of 'anomalous' findings. DISCUSSION: While imaging is frequently requested with the goal of reassuring patients, it can paradoxically have a negative impact on patient attitudes and beliefs and can influence pain behaviours. For improved patient outcomes we recommend contextualisation of radiological findings within age-related norms, use of reassuring and nonthreatening language when communicating results, and educating patients on nonpathoanatomical contributors to pain.
