WBR0913

Author	PageAuthor::Vendhan Ramanujam
Exam Type	ExamType::USMLE Step 3
Main Category	MainCategory::Inpatient Facilities, MainCategory::Emergency Room
Sub Category	SubCategory::Cardiovascular, SubCategory::Surgery
Prompt	[[Prompt::A 71 year old man is brought to the ER following an acute episode of abdominal and back pain. He also complains of nausea accompanying his abdominal pain. He is a known hypertensive and hypercholesterolemia patient for the past 15 years who is on regular treatment. He was diagnosed with an abdominal aortic aneurysm during routine ultrasound screening of his abdomen before 6 years. He is a known smoker for the past 20 years smoking half pack a day and denies taking alcohol or illicit drugs. On physical examination, he looks diaphoretic and his abdomen is diffusely mildly tender. Patient is relatively obese and thus no mass is palpated. His vitals are found to be blood pressure of 80/50 mmHg, pulse rate of 118/minute, respiratory rate of 18/minute and temperature of 36.4 C. Suspecting a rupture of his abdominal aortic aneurysm, the next best step in management of this patient is?]]
Answer A	AnswerA::A focused abdominal ultrasonography to confirm the aneurysm before the surgery
Answer A Explanation	[[AnswerAExp::Incorrect-A focused abdominal ultrasonography to confirm the aneurysm before the surgery can be done on hemodynamically unstable patients without a previously known history of AAA and systolic blood pressure > 90 mmHg.]]
Answer B	AnswerB::Emergent transfer of the patient to the operating room for immediate control of hemorrhage and repair of the aneurysm
Answer B Explanation	[[AnswerBExp::Correct-Hemodynamically unstable and known AAA patients with systolic blood pressure < 90 mmHg should be emergently rushed to the operating room for immediate control of hemorrhage and repair of the aneurysm while hemodynamically unstable patients without a previously known history of AAA and systolic blood pressure > 90 mmHg can be taken for a focused ultrasound examination to confirm the aneurysm prior to abdominal exploration.]]
Answer C	AnswerC::Abdominal CT to confirm the aneurysm rupture and for evaluating whether an endovascular repair is feasible or not
Answer C Explanation	AnswerCExp::'''Incorrect'''-Abdominal CT to confirm the aneurysm rupture and for evaluating whether an endovascular repair is feasible or not can be done on hemodynamically stable patients suspected of having a ruptured AAA.
Answer D	AnswerD::Conservative management of the patient while observing
Answer D Explanation	[[AnswerDExp::Incorrect-Conservative management of the patient with nasal oxygen, intra venous fluids, cardiac and blood pressure monitoring should be started while transferring the patient to the operating room. But then having the patient on observation will increase the risk of mortality.]]
Answer E	AnswerE::Decision for a comfort care
Answer E Explanation	AnswerEExp::'''Incorrect'''-Decision for a comfort care can be done on patients who deny treatment and on those who are high-risk poor candidates for surgery with several comorbidities.
Right Answer	RightAnswer::B
Explanation	[[Explanation::Patients with ruptured abdominal aortic aneurysm (AAA) may have different presentations. The most typical manifestation of rupture is abdominal or back pain with a pulsatile abdominal mass. However, the symptoms may be vague, and the abdominal mass may be missed as in this case where the patient is relatively obese. Symptoms like groin pain or flank mass may confuse the diagnosis with renal calculus, diverticulitis, incarcerated hernia, or lumbar spine disease. Hemodynamically unstable and known AAA patients with systolic blood pressure < 90 mmHg should be emergently rushed to the operating room for immediate control of hemorrhage and repair of the aneurysm. Proximal aortic control in the operating room should be attained at the earliest while waiting for type-specific blood components. Endo vascular aneurysm repair is superior to an open repair. Hemodynamically unstable patients without a previously known history of AAA and systolic blood pressure > 90 mmHg can be taken for a focused ultrasound examination to confirm the aneurysm prior to abdominal exploration. Educational Objective: Hemodynamically unstable and known AAA patients with systolic blood pressure < 90 mmHg should be emergently rushed to the operating room for immediate control of hemorrhage and repair of the aneurysm while hemodynamically unstable patients without a previously known history of AAA and systolic blood pressure > 90 mmHg can be taken for a focused ultrasound examination to confirm the aneurysm prior to abdominal exploration. Educational Objective: References: ]]
Approved	Approved::Yes
Keyword	WBRKeyword::Abdominal aortic aneurysm
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