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A 56-year-old man presented to the ED with abdominal pain that began several hours earlier.

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He had locked himself out of his house and was crawling through the window when he experienced an abrupt onset of abdominal pain. He felt something “pop” as he slid over the window sill and stood up. The pain was periumbilical in location and radiated to the middle of his back. He described it as a dull “gas” pain. He felt slight nausea, but had no vomiting, diarrhea, constipation, fever, or difficulty urinating. There was no chest pain or shortness of breath. He had never experienced similar pain in the past.

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The patient had no prior medical problems aside from an elevated blood pressure that had been noted one year earlier. However, he did not follow up or receive antihypertensive medications. He smoked one-half a pack of cigarettes per day. He did not drink alcohol or use illicit drugs. He worked as an electrician for the municipal transit authority.

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On examination, he was overweight and appeared comfortable, but periodically was in distress when the abdominal pain recurred. His blood pressure was 156/90 mm Hg, pulse 94 beats/min, respirations 18 breaths/min, temperature 99.2°F, and oxygen saturation 95% while breathing room air. His lungs were clear. His heart had a regular rhythm without murmur, gallop, or rub. His abdomen was obese but not distended. There was mild diffuse tenderness, but no focal tenderness, rebound tenderness, or palpable mass. Bowel sounds were normal and there were no bruits. The right flank was tender.

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The EKG showed left ventricular hypertrophy with strain (lateral T wave inversions). Blood test results showed a leukocyte count of 12,300 cells/mm3, hematocrit 41.5%, normal electrolytes, and normal renal and liver values. A urinalysis showed 1+ blood and 10–20 RBC/high power field.

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The chest radiograph was interpreted as showing a tortuous aorta (Figure 1).

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  • Is the chest radiograph normal?
  • Which disorders should be suspected in this patient?
  • Is further diagnostic imaging needed?

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Bedside abdominal ultrasonography showed no abdominal aortic aneurysm, gallstones or hydronephrosis. An abdominal CT with oral and intravenous contrast was performed. When the emergency physician called the radiologist for a preliminary report, he was first told that the CT was normal. Shortly thereafter, the radiologist called back and reported that there was an aortic dissection on the most superior slices. A faint intimal flap separated the aorta into a true and a false lumens, which were equally opacified by the intravenous contrast material (Figure 2).

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