Mr. A is a 65y/o male who presents to the emergency department (ED) with a chief complaint of a 3-day history of severe low back pain and new onset of severe abdominal pain accompanied by nausea and vomiting. Mr. A denies any history of recent back trauma or injury or any previous history of back pain. His PIN score is 8 out of 10.
PMH:
Mr. A reports that he has had hypertension for the past 10 years but recently stopped taking his education, enalapril, because he thought his blood pressure was under control. His family history includes coronary artery disease, hypertension and diabetes. His father died of a ruptured aneurysm at age 70. Mr. A smokes 1 pack of cigarettes per day for the past 20 years.
Physical Exam Findings
Moderately obese gentleman who is in acute distress.
VS are as follows:
HR 106 bpm
RR 20 br/min
BP 180/110 mm Hg
Sa02 95%
Breath sounds are clear bilaterally. Bowel sounds are hypoactive. A midline palpable mass is noted 3 cm below the xiphoid process. Radial and brachial pulses are strong bilaterally, but femoral, posterior tibial, and dorsalis pedis pulses are faintly palpable bilaterally. Capillary refill in the upper extremities is brisk, less than 3 seconds. Capillary refill in the lower extremities is greater than 3 seconds. Cranial nerves I through XII are intact and patient remains awake, alert, and oriented times three.
Mr. As 12 Lead ECG indicates left ventricle hypertrophy but no ST or T-wave changes in any leads. Cardiac enzymes are not elevated. Chest S-Ray reveals no widened mediastinum and no evidence of cardiopulmonary disease. Mr. A also receives a CT scan with contrast which reveals a 6.5 cm infra-renal AAA. He is taken to the operating room for surgical management of his AAA.
Answer the following questions about his case and post operative care in the ICU:
1. Define an AAA and distinguish it from an aortic dissection.
2. Discuss the pathophysiology of an AAA.
3. Discuss the presenting signs and symptoms that Mr. A has. Include the reason these signs and symptoms occur.
4. Discuss the risk factors for AAA including all of those exhibited by Mr. A.
5. In addition to CT with contrast, another diagnostic test for AAA is abdominal ultrasound (US). What are the advantages of US? What are the advantages of CT with contrast?
6. AAA can be managed both surgically and non-surgically (medical management).
a) Explain the medical or non-surgical management needs of a patient with Mr. As history. (drug therapies)
b) Identify the criteria that determine when the patient can no longer be medically managed and should have surgery.
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