X-ray chest shows aortic enlargement. Possibilities to be considered are aortic aneurysm, aortic dissection and unfolding of aortic arch in the elderly. In the given clinical scenario of a person presenting with pain in the left scapular region, an aortic dissection has to be considered first. CT Aortogram can confirm the diagnosis of aortic dissection and delineate the extent of dissection to decide on management. A bedside echocardiogram may also show the aortic dissection flap in the ascending aorta if the echo window is good. Echocardiogram is usually considered first because of easy availability in the emergency setting. But a negative echo study does not rule out aortic dissection and CT aortogram should be considered if the clinical situation warrants.