A 56-year-old man presented to the ED with abdominal pain that
began several hours earlier.
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.
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
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.
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
The chest radiograph was interpreted
as showing a tortuous aorta (Figure 1).
- Is the chest radiograph normal?
- Which disorders should be suspected in this
- Is further diagnostic imaging needed?
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
Superior CT slice shows an intimal flap (arrow) spanning ...