Chapter 6: Diseases of the Thoracic Aorta and Aortic Arch
ERIC M. ISSELBACHER, MD
A 74-year-old man presents to the emergency department at 10 PM with complaints of severe chest pain. He has a history of hypertension for which he is on a diuretic, but has no other known cardiovascular disease. He recounts that he was bending over to pick up his shoes when he felt the sudden onset of sharp chest and back pain, which he rated as 9 out of 10 in severity. He denies any associated shortness of breath, but is diaphoretic. On physical exam, his blood pressure is 138/70 and equal in both arms, heart rate is 92, and respiratory rate is 20. His temperature is 37.3° C. His lungs are clear. His cardiac exam is notable only for a I/IV decrescendo diastolic murmur at the left upper sternal border. His jugular venous pressure is 7 cm and his carotid pulses are 2+ bilaterally, without bruits. His peripheral pulses are normal throughout. His abdominal and neurologic exams are unremarkable. His ECG shows normal sinus rhythm, with left atrial enlargement and nonspecific ST-segment and T-wave abnormalities. His chest x-ray is unremarkable. His hematocrit is 39, WBC is 12.5, and creatinine is 1.3.