Dissecting the Presentation 
Commentary by Shirley Beng Suat Ooi, MBBS (S'pore)
A 78-year-old woman with a past medical history of hypertension was in good health until she experienced acute onset of confusion, which resolved after a few minutes. Then she had two episodes of black and "tarry" foul-smelling diarrhea (i.e., melena, usually indicative of gastrointestinal bleeding). She was concerned about the symptoms so presented to the hospital. On presentation, she had no abdominal pain, chest pain, shortness of breath, or focal weakness in her arms or legs.
Her physical examination was notable for tachycardia. Her mental status examination was normal. Laboratory tests showed mild anemia and new acute renal insufficiency. Chest radiograph revealed some right hilar fullness but was otherwise negative, and electrocardiogram showed sinus tachycardia.
The patient was diagnosed with a transient ischemic attack and possible gastrointestinal bleeding, and she was admitted to a telemetry unit for monitoring and ongoing testing. She generally did well with no further confusion and resolving diarrhea. She did have a persistent sinus tachycardia.
On the morning of hospital day 2, she was found unconscious by the nursing staff and found to be in cardiac arrest; her cardiac rhythm was pulseless electrical activity. Despite maximal resuscitation efforts, the patient died.
Autopsy revealed the cause of death to be an acute aortic dissection (tear in the aorta) extending from the ascending aorta to the renal arteries, along with an acute hemothorax (blood in the chest cavity). The dissection was probably present on admission and the tear in the aorta had impaired blood flow leading to all of her symptoms, including the transient ischemic attack, the gastrointestinal bleeding, and the renal failure. The dissection likely worsened while the patient was hospitalized, and its rupture into her chest cavity was the terminal event.
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