An obese 77-year-old woman presents with dyspnea, cough, hemoptysis, and diaphoresis. She is tachypneic with crackles and wheezing, and there is a significant difference in blood pressure between her arms. Which condition should you suspect?

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The key idea is that a noticeable difference in blood pressure between the arms is a red flag for acute aortic pathology, such as a thoracic aortic aneurysm with dissection. When the aorta dissects, the intimal flap can narrow or occlude branches like the subclavian artery, causing one arm to have a significantly different systolic pressure from the other. In an elderly patient with risk factors, this makes acute aortic involvement the most concerning and likely diagnosis given the presentation.

The other signs—dyspnea, diaphoresis, coughing, and hemoptysis—can occur with serious cardiopulmonary events, but they don’t explain a prominent interarm blood pressure discrepancy as well as an aortic aneurysm/dissection does. This vascular catastrophe remains the best-fitting explanation, and it requires urgent imaging and stabilization.