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    A 49 year old white male with a history of ethanol abuse, bronchial asthma and hypertension presents to the ED with a six hour complaint of severe chest pain. He became markedly dyspnic two hours prior to his presentation.
    Physical exam reveals that the patient is in marked respiratory distress and complains of lower anterior and posterior chest pain. BP 110/70 mm Hg in the right arm. Pulse is 110/min and regular. Respirations labored at 35/min. He is afebrile. Neck veins are flat at 30 degrees and there is no HJR.

     S1 is muffled. There is a grade 2/6 systolic ejection murmur at the LUSB together with a very brief grade 2/6 early diastolic decrescendo murmur. An S4 gallop is present at the apex together with a soft, intermittent S3. The lungs are relatively clear, except for occasional scattered rhonchi. The abdomen is unremarkable and there is no pitting edema of the legs.

Which ONE of the following is the most likely diagnosis?

• A. Acute MI with papillary muscle dysfunction
• B. Type B aortic dissection
• C. Severe acute aortic regurgitation
• D. Acute pulmonary embolism with pulmonary regurgitation
• E. Acute MI with ruptured papillary muscle