Abdominal aortic aneurysm USMLE

Abdominal aortic aneurysm USMLE question 1

  1. A 70-year-old man presents to the emergency department because of the rapid onset of severe abdominal pain radiating to his back. The patient states he has hypertension, peripheral artery disease, and diabetes mellitus. Current medications include hydrochlorothiazide, amlodipine, glyburide, and pravastatin. He denies symptoms of nausea and vomiting. Physical examination reveals a pallid patient in distress with a pulse of 112/min and a blood pressure of 70/50 mm Hg. ECG demonstrates no acute ischemic changes. For this patient with an acute abdomen what will be the best next step in management

A. Abdominal ultrasound

B. CT of the abdomen with contrast

C. Measure serum amylase and lipase levels

D. Measure serum lactate level

The correct answer is A.
On the basis of PMH and the presentation of hypotension, and the quality and location of the pain, a ruptured abdominal aortic aneurysm should be the diagnosis. The significant history of hypertension and diabetes is also contributory. In an unstable patient, abdominal ultrasound is the best next test of choice as it provides rapid guidance for the diagnosis of an AAA. A Focused Assessment with Sonography for Trauma (FAST) scan is useful for detecting free fluid in the abdomen, such as bleeding from AAA.

Abdominal CT with contrast is the preferred imaging modality for abdominal aortic aneurysm (AAA) in a hemodynamically stable patient. Contrast helps to visualize the vasculature, possibly guiding the repair. However, suspicion, in this case, should be high for a ruptured AAA, and the patient is not hemodynamically stable, so this is not correct answer.

A combination of hypotension, abdominal pain radiating to the back, and significant history of both HTN and DM must raise suspicion of ruptured AAA. Abdominal ultrasound is used for diagnosis in unstable patients.

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Abdominal aortic aneurysm USMLE question 2

  1. A 72-year-old man presents for his first check-up in 20 years. He has been a smoker for 35 years and typically drinks two-pack of beer per day. On examination, he has a pulsatile abdominal mass. He is referred for a CT abdomen; results are shown in the image. Which of the following would most likely have prevented this progression?
Abdominal aortic aneurysm usmle
Img Credit: James Heilman, MD / CC BY-SA (https://creativecommons.org/licenses/by-sa/3.0)

A. Abstinence from alcohol

B. Aspirin therapy

C. Cholesterol screening

D. Smoking cessation

The correct answer is D.
Smoking is a major risk factor for abdominal aortic aneurysm formation, growth, and rupture. All patients with AAA or with a family history of AAA should be strongly encouraged to stop smoking. AAAs are defined as focal dilatations of the abdominal aorta that are 50% greater than the proximal normal segment of the aorta. The CT abdomen clearly reveals a grossly dilated abdominal aorta with an evident thrombus forming a crescent-shaped ring around the lumen of the aorta. Apart from smoking, the age of 65 and older, atherosclerosis, male gender, and family history are other risk factors for developing AAA.

Smoking is a major risk factor for AAA formation, growth, and rupture. All men between 65-75 years of age with a history of smoking should undergo screening ultrasonography to evaluate for an AAA

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Abdominal aortic aneurysm USMLE question 3

  1. A 78-year-old man presents to the clinic with a complaint of a dull lower back pain that is not affected by positional changes. It has been gradually worsening over the course of the past several months. His blood pressure is 151/84 mm Hg and pulse is 78/min. Abdominal examination reveals a pulsatile mass approximately 5.5 cm in diameter and palpable in the epigastric area. Peripheral pulses are normal. Which of the following is the most likely diagnosis for this patient?

A. Abdominal aortic aneurysm

B. Colonic obstruction

C. Pancreatitis with pseudocyst

D. Peptic ulcer disease

The correct answer is A.
Abdominal aortic aneurysm are typically asymptomatic until rupture but it can occasionally cause a dull lower back or flank pain. The aneurysms are predominantly caused by atherosclerosis. In around 90% of cases, AAA occurs below the renal arteries. Abdominal ultrasonography is a gold standard for screening for AAA because its sensitivity is around 100%. The normal diameter of the aorta is approximately 2 cm, and surgery is generally indicated above 5.5 cm. The finding of a pulsatile epigastric mass is highly suggestive of AAA.
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