When Common Symptoms Hide Uncommon Dangers

Author: Katie Holford, Faisal Faruqi / Editor: Sarah Edwards / Codes: CC7, CP1, SLO1 / Published: 02/07/2026

A 49-year-old female presents to the Emergency Department (ED) after being recently discharged from hospital following a community acquired pneumonia and constipation. She has not opened her bowels in four days. She is passing flatus and feels bloated. She has no urinary symptoms.

This morning, she woke up with a sudden onset of severe chest/epigastric pain, which she describes as stabbing, constant and radiating through to her back, unlike anything she has experienced before. The discomfort was so severe that she became doubled over shouting in pain. Alongside the pain, she noticed a sensation of palpitations. She has had no episodes of syncope or oedema, no new coryzal symptoms or shortness of breath.

Past Medical History:

Atrial fibrillation on a direct oral anticoagulant (DOAC), hypertension, heart failure on sacubitril/valsartan, depression, arthritis, hypercholesterolaemia and fibromyalgia.

Allergies: Paracetamol, Tramadol

On Arrival / Resus:

The patient is clerked on arrival. Her observations are:

• Heart rate: 110
• Blood pressure: 176/82
• Temp 36.5
• Respiratory rate: 26
• Oxygen: 98% RA
• GCS 15 with a severe pain score of 8/10

Cardiovascular System:

Her radial pulse is regular. There is no chest wall tenderness on palpation. Heart sounds I + II with no added sounds. Her breathing is vesicular, though difficult to assess due to significant shouting. There is no evidence of oedema.

Abdominal Examination:

Her abdomen appears large but remains soft on palpation. An umbilical mass is present and there is evidence of guarding. The abdomen is globally tender, though there are no signs suggestive of acute peritonism.

Given the history of severe chest pain radiating through to the back, the differentials considered are:

Differentials:
Consider aortic dissection
Consider perforation/obstruction
?MI

Therefore, a CT Angiogram of the whole Aorta is ordered. The CT impression is an isolated coeliac artery dissection with flap propagating to the common hepatic artery. Similar to the images here.