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V7) Sudden onset abdominal pain radiating to the back
Review the Learning Outcomes, Hx, PE and Labs, and begin the module with your Provisional Diagnosis. Keep hitting "Next" to move through the module.
Learning Outcomes
- Articulate your relationship with the consulting diagnostic radiologists in the evaluation of a patient with abdominal pain.
- Review the DDx considerations in a patient with abdominal pain.
- Identify the spectrum of imaging findings in appropriate modalities for evaluating a patient with abdominal pain.
History
A 64-year-old male with 90 pack year history presents due to sudden onset severe abdominal pain radiating to his back. The patient has a history of peripheral vascular disease requiring two stents in the right lower extremity, COPD, uncontrolled hypertension and hyperlipidemia with poor medication compliance.
Physical Exam
BP: 105/73, HR 102, RR 20, Temp 36.3, O2 saturation 100%. Abdominal exam: Palpable, 6cm pulsatile mass.
Labs
Hgb: 13.3 (nl 13.2-16.6), Lipase: 15 u/L (nl: 0-160u/L)
Provisional Diagnosis
Select the Dx you believe is most appropriate
The patient’s severe abdominal pain radiating to the back, history of COPD, uncontrolled hypertension, and hyperlipidemia, finding of a large, palpable pulsatile mass, strongly suggest a diagnosis of a ruptured AAA. While the hemoglobin is apparently normal, it is likely due to a decreased in blood volume without change in hemoglobin concentration.
Well done. You were correct
Potential Acuity
What is your assessment of the likely acuity for this patient?
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This patient requires emergent workup as their condition is immediately life-threatening.
First Imaging Study
What is the first imaging study you will order?
The patient should undergo imaging as they are hemodynamically stable. The best initial study would be a CTA of the chest, abdomen, and pelvis to assess the aorta. For the purposes of this teaching case, the CT of the chest is excluded.
Well done. You were correct
Pertinent Imaging Observations
Click on the links below to view images from the study, and assess these key findings as best you can.
CTA abdomen and pelvis
There is evidence of aortic dissection.
There is no intimal flap, double, or triple lumen to suggest the presence of an aortic dissection.
There is an aortic aneurysm.
The infrarenal abdominal aorta is significantly dilated.
There is evidence of aortic rupture.
There is a retroperitoneal aortic rupture at the level of the infrarenal abdominal aorta that is extending into the psoas muscle.
View the full study if you'd like to take a look yourself.
Second Imaging Study
What is the next imaging study you will order?
The suspected diagnosis is confirmed with the CTA.
Well done. You were correct
What is your Diagnosis now that you have seen the imaging results?
The AAA ruptured into the retroperitoneal space.
Current Acuity
Initially, you selected and we suggested acuity.
Has your concern for this patient changed?
Vascular surgery should be immediately consulted for operative evaluation.
Assessment and Plan
Please provide your assessment and plan for this patient
The patient is a 90-year-old male presenting with severe abdominal pain radiating to the back with a palpable pulsatile, abdominal mass. CTA confirmed the diagnosis of a ruptured AAA. The patient will require emergent vascular surgery evaluation.
Lessons Learned:
- Abdominal aortic aneurysms are most likely to rupture in the posterolateral portion of the aorta and into the retroperitoneal space. Such rupture has significantly increased odds of survival as it is contained in the retroperitoneal space compared to an intraperitoneal rupture.
Socioeconomic Factors: Patients with lower socioeconomic status with ruptured abdominal aneurysm were found to have worse outcomes. Therefore, there is a need for increased attention and strategic efforts in these groups to help reduce disparities.
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