A 77-year-old woman is complaining of shortness of breath. As you begin to move her, she starts to have tearing pain in her lower back. What should you suspect?

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The scenario tests recognizing an aortic catastrophe, specifically an abdominal aortic aneurysm rupture. In an elderly patient, sudden, tearing back pain that arises as you move suggests the aorta is involved and may be rupturing or dissecting in the abdominal region. Abdominal aortic aneurysm rupture commonly presents with abrupt, severe back or abdominal pain and can rapidly lead to hypotension and shock, which also explains the new shortness of breath as perfusion declines. Other conditions fit less well: a heart attack tends to present with chest pressure or jaw/arm symptoms rather than a tearing back pain pattern; a pneumothorax causes sharp chest pain with unilateral breath sounds and obvious respiratory distress; aortic dissection can also cause tearing pain but is more typically described as chest or back pain with different distribution, whereas the scenario’s back-focused tearing pain in an older patient with vascular risk factors points most strongly toward AAA rupture.