Question

Case study #5

A 66 year-old male presents to the local ER at 6 AM. The patient reports that he has been having severe chest pain since last night before he went to bed. The patient says that he just simply thought that he was having a “bad case of indigestion and gas” after eating a bunch of fatty foods while watching the football with his friends last night. He says he took Pepto Bismol to help ease the pain. The patient says that he woke up around 3 AM this morning with increased upper and mid abdominal pain. He described the pain as “sharp and gnawing” right underneath his rib cage. The patient was immediately brought back to a room from triage. The ER staff was about to do a shift change and so the overnight physician medically screened the patient and ordered a standard set of lab tests. The patient was given a 325 mg aspirin tablet after getting undressed and laying down on the bed. After approximately 15 min after arrival to his room, the patient started writhing in the bed complaining of increased abdominal pain. The patient reported his pain level of 20 on a scale of 1 to 10. The patient’s history is significant for noncompliant hypertension, hypercholesterolemia, moderate obesity, and smoking 1.5pk/d, but had stopped five years ago.

Upon physical examination, the patient was diaphoretic, and had pallor. Strong pulsations were found with light palpation over the middle of the abdomen. With deeper palpation, aortic bruits were detected by auscultation. There was radiation of the pain to the lumber area of the back. The morning physician ordered a series of diagnostic imaging studies to determine if there were any issues contributing to the patient’s pain within the abdomen. After the imaging studies were completed. The radiologist called the physician on duty and said that patient needed immediate surgery. One of the imaging studies done showed there was a 5.4 cm diameter measurement of the aorta. Arrangement were immediately made to fly the patient to a trauma center for surgery.

1. What condition does this patient have?

2. What are the diagnostic testing that the morning physician ordered?

3. What are the risk factors that contributed to the patient’s condition?

4. What is the proper protocol for treatment of the patient’s condition? How is it done?

Answer 1

1. This patient is suffering from abdominal aortic aneurysm. This is indicated by the imaging study

2. The risk factors in this patie t are: smoking, hypercholesterolemia and uncontrolled hypertension.

Other risk factors include hyperhomocysteinemia, coronary artery disease, Marfan's syndrome, alcohol use etc.

3. The imaging study ordered was Contrast enhanced CT scan of the thorax and abdomen. This has showed a dilation of aorta to 5.4cm which indicated aortic aneurysm.

4. The treatment protocol takes into consideration the risks and benefits of surgery. The risks of aneurysm rupture is considered and compared to risk from surgery. The goal of the treatment is to prevent rupture of aortic aneurysm, which has very high mortality rate.

It also takes into consideration the age of the patient.

Aortic aneurysms with size less than 4 cm, the annual riskbof rupture is negligible while for an aneurysm with size more than 8cm, the risk is 30 to 50 percent per year.

Other factors that add to risk of rupture include smoking, female sex and COPD.

The society for vascular surgery has recommended surgical repair of all aortic aneurysms more than 5.5 cm.

Endovascular Vs open repair is another consideration. In general, younger patients, patients with connective tissue disorder, situations in which anatomy is not suitable for endovascular repair are posted for open repair.