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Difficulty: EasyFormulating a Differential Diagnosis

A 65-year-old man presents to the emergency department with the sudden onset of severe, "tearing" chest pain that radiates to his back. He has a 15-year history of poorly controlled hypertension. On physical examination, his blood pressure is 185/110 mmHg in the right arm and 145/90 mmHg in the left arm. His heart rate is 110/min. An electrocardiogram shows sinus tachycardia and voltage criteria for left ventricular hypertrophy, but no acute ST-segment or T-wave changes. When formulating the differential diagnosis for this patient, which of the following life-threatening conditions must be prioritized?

  1. Acute aortic dissectionAnswer
  2. B
    Acute pericarditis
  3. C
    Pulmonary embolism
  4. D
    Esophageal perforation
  5. E
    Costochondritis

Answer

Acute aortic dissection
The correct answer is acute aortic dissection because the patient presents with classic features that demand its immediate inclusion at the top of the differential diagnosis. The sudden onset of severe, "tearing" chest pain that radiates to the back, combined with a history of long-standing hypertension and a significant blood pressure discrepancy (>20 mmHg difference) between the arms, is the hallmark presentation of an aortic dissection. Recognizing this pattern is essential to avoid premature closure on more common but incorrect diagnoses.

Step-by-Step Solution

1
Analyze the patient's history and symptoms.
The patient has a history of poorly controlled hypertension and presents with sudden-onset, severe, tearing chest pain radiating to the back.
Identifying the quality, onset, and radiation of pain helps narrow the initial differential diagnosis.
2
Evaluate the physical examination findings.
There is a significant blood pressure discrepancy between the right and left arms (185/110 mmHg vs. 145/90 mmHg).
A blood pressure difference of >20 mmHg between the arms is a major red flag that points toward a vascular emergency rather than a cardiac or pulmonary etiology.
3
Synthesize the findings to formulate the most likely differential diagnosis.
The combination of severe tearing pain, radiation to the back, and asymmetric blood pressures makes acute aortic dissection the most critical condition to prioritize.
Failing to prioritize this must-not-miss diagnosis leads to premature closure and potentially fatal delays in management.

Key Concept

Formulating a differential diagnosis for acute chest pain requires recognizing classic 'red flag' presentations, such as tearing pain and blood pressure discrepancies, which strongly suggest acute aortic dissection.
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Formulating a Differential Diagnosis

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