Please help to review my interpretation of this case study.  feel free to
comment and point out the mistakes.  Thanks

Case History
A 69-year-old man was a heavy smoker and presented to his doctor with a
painful, black big toe.  This was gangrenous on examination and he was
admitted to hospital urgently for treatment and surgical amputation.  He
made a good recovery and was well for a year.  He then started to develop
pain in the lower back which came and went but was not severe enough to
complain to his doctor.  On one occasion, however, he experienced
excruciating pain in the lower right back and rapidly became shocked and
collapsed with a pulse rate of 120/min and a systolic {*filter*} pressure of 60
mmhg.  He was rushed to hospital but died in the ambulance.

A post-mortem examination was performed at which a large abdominal aneurysm
was found ruptured.  There were 3 litres of fresh {*filter*} clot in the
retroperitoneum, tracking up behind the right kidney.  The aorta showed
severe atheroscierosis elsewhere.

1. How might you connect the episode of gangrene in the toe with the final
pathology in this man?

Ans:
Ans:  The heavy smoking of the man may have resulted in the formation of
atheromatous plaques that lead to atherosclerosis.  The site of atheroma
could be on an aorta serving the lower portion of the body.  The gangrenous
toe could be caused by vascular occlusion of the supplying {*filter*} vessel.
The decrease in systolic pressure before death is due to the rupture of the
aneurysm which caused the {*filter*} clot in the retroperitoneum
region(retroperitoneum haemorrhage).  The internal loss of {*filter*} made the
man go into hypovolaemic shock.  The area of pain is consistent with the
site of rupture, behind the kidney.

Could be THE aorta not AN aorta...there is only one aorta.

The gangrenous toe was probably due to an embolic event.

The embolism could have come from the heart if the person had atrial
fibrillation and not adequately anticoagulated.

Other sources include ulcerated plaques in the aorta, iliac arteries, fem{*filter*}
arteries.

Yes, indeed.  The embolism would travel down until it could go no further,
clotting off that {*filter*} vessel.

But remember, smoking like he did, atherosclerosis affects all arteries.  COuld
have been the final occlusion of the applicable artery in the foot.  Also
unsure if this particular patient was diabetic.

Actually, the site of the rupture was probably the posterior aortic wall.  he
{*filter*} just happened to track into the retroperitoneum behind that particular
kidney.  Post-mortem should identify the actual site of the rupture.

What is the most common site for aortic rupture?

--
Edward J. Mathes, RPA-C
Internal Medicine                         \\\\\\I//////

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