Case of the Month September 2015

Case submitted by Jonathan Frankel, MD, and Thomas J. Learch, MD.


  • 86 year old male presents to the ED after a fall at home. He was in the bathroom when he suddenly became lightheaded and fell. He was noted by the paramedics at the scene to be hypotensive (80s/60s). No focal weakness. No recent illness.
Past Medical History: Hypertension, coronary artery disease, myocardial infarction, coronary stent placement and abdominal aortic aneurysm


Past Surgical History: laparoscopic hernia repair, retropubic prostatectomy


Family Medical History: Mother and brother stroke; Father prostate cancer


Social History: Daily smoker since 1979

Baseline Vitals from prior MD appointment in 2014:
–BP: 151/91 mmHg
–Heart Rate: 76
–Respiratory Rate: 17
–SpO2: 98 %



Patient remained hypotensive with systolic blood pressure gradually dropping into the high 60s.
His breathing was labored and tachypneic.



  • INR = 1.3
  • PTT = 29
  • Hgb/Hct = 9.4/29.4 (11.9/40.0 [baseline in 2014])
  • Lactate = 4.3
  • Tbili = 1.9
The emergency room physicians were concerned for continued rapid worsening of his vitals so they sent him for an emergent CT.

For larger images, please click on End Stage 1 and End Stage 2 .


What's the diagnosis?

  • Pyelonephritis
  • Aortic dissection
  • Aortic aneurysm
  • Aortic rupture


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