59-year-old male presents with sudden onset tearing chest pain radiating to his back between his shoulder blades, rated 10/10, onset abruptly 30 minutes ago while lifting a bag of groceries. He states the pain 'ripped through' him and immediately dropped him to his knees. He has never had pain like this. He is pale, diaphoretic, and appears in extreme distress.

History of longstanding poorly controlled hypertension and Marfan syndrome diagnosed at age 22. He takes amlodipine but is non-compliant with follow-up. He has a family history of aortic aneurysm — his brother required aortic surgery at age 55. He does not smoke or drink. No prior cardiac history.

Right arm BP 186/104 mmHg, left arm BP 148/88 mmHg — a blood pressure differential of 38 mmHg systolic between arms. HR 112 bpm, RR 22 breaths/min, Temp 37.0°C, SpO2 94% on room air. Patient is in severe distress. Pulses diminished in left radial compared to right. Cardiac monitor shows sinus tachycardia.

Extremity BP differential >20 mmHg and pulse differential are highly significant findings. Aortic regurgitation murmur (diastolic, decrescendo) heard at the right upper sternal border. No stroke symptoms present. No abdominal tenderness. Cardiothoracic surgery called immediately. IV esmolol infusion started to lower HR to <60 bpm and reduce aortic wall stress. Sodium nitroprusside added to titrate systolic BP to 100–120 mmHg target. Two large-bore IVs placed; type and screen sent.

CT aortography with contrast: Type A aortic dissection — intimal flap identified extending from the aortic root through the ascending aorta into the aortic arch; no extension below the diaphragm. Pericardial effusion present (small). Troponin mildly elevated at 0.8 ng/mL — possible coronary ostial involvement. Chest X-ray: widened mediastinum (>8cm), loss of aortic knob contour. D-dimer markedly elevated at 6,400 ng/mL. Patient taken emergently to OR for surgical repair.

Diagnose It — Archive Puzzle #16