A 58-year-old man with a history of poorly controlled hypertension presents to the emergency department with a sudden onset of severe, "tearing" chest pain that radiates to his back between his shoulder blades. He is diaphoretic and visibly anxious. Vital signs show a blood pressure of 190/110 mm Hg in his right arm and 150/90 mm Hg in his left arm, a heart rate of 115/min, and a respiratory rate of 22/min. Cardiac auscultation reveals a new diastolic decrescendo murmur at the right upper sternal border. An electrocardiogram shows sinus tachycardia with no ST-segment or T-wave abnormalities. A chest radiograph demonstrates a widened mediastinum. Which of the following is the most likely diagnosis?
- Acute aortic dissectionCevap
- BAcute myocardial infarction
- CAcute pericarditis
- DPulmonary embolism
- EEsophageal perforation
Cevap
Acute aortic dissection
The correct answer is acute aortic dissection. This patient presents with the classic triad of a thoracic aortic dissection: sudden onset of tearing chest or back pain, a pulse deficit or blood pressure differential between the upper extremities, and a widened mediastinum on chest radiograph. The new diastolic murmur indicates aortic root involvement leading to acute aortic regurgitation. This is a "must-not-miss" diagnosis that requires immediate surgical or medical intervention depending on the anatomical classification (Stanford Type A vs. Type B).
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Anahtar Kavram
The classic presentation of acute aortic dissection includes sudden onset tearing chest pain radiating to the back, asymmetric blood pressures, and a widened mediastinum on chest radiograph.