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Characterize the symptoms: ❑ Cardiac ❑ Chest pain described as tearing, ripping, sharp or stabbing* ❑ Abrupt onset of pain and increasing in intensity* ❑ Chest pain worsened by deep breathing or cough and relieved by sitting upright ❑ Anxiety ❑ Palpitation ❑ Fainting ❑ Sweating ❑ Pale skin ❑ Rapid, weak pulse ❑ Shortness of breath ❑ Peripheral edema ❑ Rapid breathing ❑ Orthopnea ❑ Extra cardiac ❑ Abdominal pain or back pain ❑ Flank pain ❑ Lower and upper extremity weakness, numbness and tingling ❑ Nausea and vomiting ❑ Symptoms suggestive of stroke ❑ Swallowing difficulties due to pressure on the esophagus ❑ Gastrointestinal bleeding ❑ Altered mental status ❑ Feeling of impending doom ❑ Hemoptysis ❑ Drooping of eyelids ❑ Decreased or no sweating ❑ Haematemesis ❑ Hoarseness of voice

Obtain a detailed history: ❑ Past medical history ❑ Hypertension ❑ Pheochromocytoma ❑ Family history ❑ Aortic disorder* ❑ Connective tissue disorder* ❑ Anatomic deformities ❑ Aortic valve disease* ❑ Thoracic aortic aneurysm* ❑ Coarctation of aorta ❑ Polycystic kidney disease ❑ Iatrogenic ❑ Recent aortic manipulation* ❑ Chronic steroid usage ❑ Immunosuppressive therapy ❑ Lifestyle ❑ Cocaine abuse ❑ Heavy weight lifting ❑ Trauma ❑ Genetic ❑ Marfan's syndrome* ❑ Ehlers-Danlos syndrome ❑ Turners syndrome ❑ Biscuspid aortic valve ❑ Loeys-Dietz syndrome ❑ Familial thoracic aneurysm and dissection syndrome ❑ Inflammatory vasculitis ❑ Takayasu arteritis ❑ Giant cell arteritis ❑ Behcet's arteritis ❑ Pregnancy ❑ Infections involving the aorta

Examine the patient: ❑ General examination: ❑ Pulse rate - ↑ ❑ Blood pressure - ↑ or ↓ ❑ Respiratory rate - ↑ ❑ Wide pulse pressure ❑ Difference in the blood pressure in both extremities* ❑ Signs of shock (hypoperfusion)* ❑ Pulse deficit involving carotid, femoral or subclavian arteries* ❑ Increased sweating or anhidrosis ❑ Head/neck examination: ❑ ↑ JVP ❑ Signs of vocal cord paralysis ❑ Pemberton's sign (SVC) ❑ Venous distention in the neck and distended veins in the upper chest and arms (SVC) ❑ Cardiovascular examination: ❑ Diastolic murmur suggestive of aortic regurgitation* ❑ Wheeze (cardiac asthma) (CHF) ❑ Pericardial friction rub ❑ Respiratory examination ❑ Crackles / crepitations / rales ❑ Decreased movement of the chest on affected side ❑ Stony dullness to percussion ❑ Diminished breaths sounds ❑ Decreased vocal fremitus ❑ Pleural friction rub. ❑ Abdominal examination: ❑ Ascites ❑ Claudication of buttocks ❑ Absent femoral pulses ❑ Neurological examination: ❑ Altered mental status* ❑ Signs of peripheral neuropathy ❑ Signs suggestive of stroke* ❑ Extremity examination: ❑ Pedal edema ❑ Ophthalmological examination ❑ Miosis ❑ Ptosis

❑ Assess the severity by counting the high risk features marked in bold and by *

❑ Consider close differential diagnoses: ❑ Aortic regurgitation ❑ Aortic stenosis ❑ Aortic aneurysm ❑ Atherosclerotic or cholesterol embolism ❑ Cardiac tamponade ❑ Cardiogenic shock ❑ Cholecystitis ❑ Esophageal perforation rupture ❑ Gastroenteritis ❑ Hemorrhagic shock ❑ Hernias ❑ Hypertensive emergencies ❑ Hypovolemic shock ❑ Musculoskeletal pain ❑ Mediastinal tumors ❑ Myocardial infarction ❑ Myocarditis ❑ Myopathies ❑ Pancreatitis ❑ Pericarditis ❑ Pleuritis ❑ Peptic ulcer disease or perforating ulcer ❑ Peripheral vascular injuries ❑ Pleural effusion ❑ Pulmonary embolism ❑ Thoracic outlet syndrome

Low Risk ❑ No high risk features present ❑ Clinical presentation is not initially suggestive for dissection but aortic imaging may help in the absence of alternative diagnosis

Intermediate Risk ❑ Single high risk present ❑ Concerning presentation for acute dissection and requires aortic imaging if no alternate diagnosis can be reached

High Risk ❑ Two or more high risk features present ❑ Acute dissection requiring immediate surgical evaluation and expedited aortic imaging