A 45-year-old male presented to the emergency department of the Department of Internal Medicine on a recent rotation with a sudden onset of severe back pain while preparing to rest in bed half an hour earlier, which he thought was a “fork in the air” and could be slightly relieved by having someone pound his back. He had a history of hypertension for 3 years, which was poorly controlled. On examination: blood pressure 180/120 mmHg, heart rate 58 beats/min, generalized wet and cold, nervousness, painful expression, chest 3-5 spine pressure pain, no other obvious abnormalities. Emergency ECG normal, to be injected prednisolone 100mg slightly relieved, began to consider the possible diagnosis and the accompanying investigation: 1, the most fear of the emergency medical infarction misdiagnosis, and again the patient has hypertensive disease, ECG normal does not count, and then check the infarction three and ECG monitoring observation; 2, we are within the gods – sudden onset of severe back pain, in fact, I first thought of – spinal cord bleeding, there is a little support – hypertensive disease, but the patient does not have lower limbs Numbness and weakness, cone bundle signs, meningeal irritation signs and other positive symptoms and signs, may only be the spinal cord surface spinal vascular rupture, can wait for its possible disease to exclude lumbar puncture to confirm the diagnosis; 3, the most likely diagnosis of severe back pain also consider pneumothorax, the patient does not have air tightness and positive lung signs do not support, but still need to do a chest X-ray to exclude; 4, because the abdominal pain may also radiate to the back, especially acute cholecystitis, cholelithiasis, acute pancreatitis need to be excluded. Acute pancreatitis needs to be ruled out. Check abdominal ultrasound, blood and urine amylase, blood glucose, blood count, renal function, electrolytes, etc. A 45-year-old male, who came to the clinic half an hour ago with sudden onset of severe back pain while preparing to rest in bed, thought it was a “fork in the air” and could be slightly relieved after having his back pounded. He had a history of hypertension for 3 years, which was poorly controlled. Physical examination: blood pressure 180/120 mmHg, heart rate 58 beats/min, generalized wet and cold, nervousness, painful expression, pressure pain in the 3-5 thoracic spine, no other obvious abnormalities. 2, the urgent investigation of the ECG is normal, to be injected prednisolone 100mg slightly relieved, began to consider the possible diagnosis and the accompanying investigation: 1, the most fear of the emergency medical infarction misdiagnosis, and again the patient has hypertensive disease, the ECG is normal does not count, and then check the infarction three and ECG monitoring observation; 2, we are within the gods – sudden onset of severe back pain, in fact, I first thought is – spinal cord bleeding, there is a point can support – hypertensive disease, but the patient is not 3, the most likely diagnosis of severe back pain also consider pneumothorax, the patient does not have air tightness and positive lung signs do not support, but still need to do a chest X-ray to exclude; 4, because the abdominal pain may also be radiated to the back, especially acute cholecystitis, cholelithiasis The patient should be excluded from acute pancreatitis, check abdominal B ultrasound, blood and urine amylase, blood glucose, blood count, renal function, electrolytes, etc. The patient was in severe pain again after about 10 minutes, this time without generalized cold and wetness, the physical examination was the same as before, and he asked to go down to the ground (walking on the ground and pounding his back before coming to the clinic could relieve the pain), but he was determined not to go down to the ground, because no matter which disease is mentioned above, it may be fatal to move again, and he was given morphine 10mg, and the pain was gradually relieved. Fourth, 1 hour later, the test results returned normal, the patient is not in pain, said since the test are fine that there is no disease, or we go home, lumbar puncture – that is to draw bone marrow we do not do. But the examination is fine, then no disease? The severe pain for almost an hour can be fine? I do not believe, but also can not think of any disease, said you wait a little more observation called a consultation. The cardiology department was called to the emergency room, and at first they also said that the possibility of infarction was high, because most of the time the ECG and cardiac enzymes are changing dynamically, and the ECG can be normal at the beginning and may be abnormal only after a few hours, but then the ECG was normal, and I asked what else was there besides the infarction that was so painful, and the answer was – arterial entrapment, which is a fatal disease, and then listened to the upper sternal fossa, heart and abdomen without arterial murmurs, and put no difference in the bilateral pulse, and contacted the ultrasound -Bad, contact CT said also need to enhance – trouble, or you go to MRI, well on MRI, MRI did not enhance the side to see me in a cold sweat from the descending aorta to the abdominal aortic coarctation obviously formed, transferred to other hospital surgery. Sixth, lessons learned: outpatient emergency work to four more: more thinking, more observation, more consultation, more examination.