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A 68-year-old man with a past medical history significant for hypertension, coronary artery disease, and previous inferior myocardial infarction presents to the ED with sudden onset of severe “tearing” chest pain that radiates to the back. The pain is accompanied by diaphoresis, nausea, and lightheadedness. The patient denies loss of consciousness or evidence of syncope. Administration of sublingual nitroglycerin has not provided any relief. On physical examination, the right arm blood pressure is 80/40 mm Hg, while that in the left arm is 190/110 mm Hg. A diastolic murmur is heard at the left sternal border, which is consistent with aortic insufficiency. An ECG was obtained that showed no acute ischemic ST segment changes. On x-ray of the chest, there was evidence of a widened mediastinum.
Which of the following is the most appropriate next step in diagnosis?
(A) Transesophageal echocardiogram
(B) Transthoracic echocardiogram
(C) Upper endoscopy
(D) Ventilation-perfusion scan
(E) X-ray of the abdomen
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