step question of the day
A 56-year-old man is brought to the emergency department by his wife 30 minutes after he had severe upper back pain and hoarseness before becoming comatose. He has hypertension treated with hydrochlorothiazide. His temperature is 37°C (98.6°F), pulse is 100/min, and blood pressure is 160/80 mm Hg in the right arm and 100/60 mm Hg in the left arm. Ophthalmologic examination shows ptosis and miosis of the left eye. There is anhidrosis of the left side of the forehead, right hemiplegia, and a decreased left radial pulse. A chest x-ray shows a widened mediastinum.
Which of the following conditions is the most likely cause of these findings?
A) Dissection of the aorta distal to the left subclavian artery
B) Dissection of the aorta extending into the left carotid artery
C) Dissection of the aorta extending into the left carotid artery and distal aortic arch
D) Dissection of the proximal aorta extending into the right subclavian artery
E) Superior sulcus tumor
F) Thrombus of the left carotid artery
