USMLE Forum Archives - USMLE Step 2 CK - IM 43
IM 43
TheOne - 06-11-07 19:15
A 70 years old man comes to the clinic complaining of steady, dull back pain over the past 2 weeks. He states that he has recently moved after retiring from a career in banking and is searching for a new primary care physician. His past medical history is significant for diverticulosis, prior smoking, and hypertension. He says that he has run out of his blood pressure medication. He denies trauma to his back and otherwise feels well. On physical examination his blood pressure is 170/95 mm Hg with a pulse of 88/min. He has no tenderness over the spinal processes or paraspinal areas. His abdomen is obese but there is a suggestion of a non-tender, pulsatile mass in the epigastric region. The remainder of the physical examination is normal. Which of the following diagnoses should be considered at this time?
A. Abdominal aortic aneurysm (AAA)
B. Acute aortic dissection
C. Cauda equina syndrome
D. Lumbosacral disk herniation
E. Pancreatitis
TheOne - 06-11-07 19:15
A 70 years old man comes to the clinic complaining of steady, dull back pain over the past 2 weeks. He states that he has recently moved after retiring from a career in banking and is searching for a new primary care physician. His past medical history is significant for diverticulosis, prior smoking, and hypertension. He says that he has run out of his blood pressure medication. He denies trauma to his back and otherwise feels well. On physical examination his blood pressure is 170/95 mm Hg with a pulse of 88/min. He has no tenderness over the spinal processes or paraspinal areas. His abdomen is obese but there is a suggestion of a non-tender, pulsatile mass in the epigastric region. The remainder of the physical examination is normal. Which of the following diagnoses should be considered at this time?
A. Abdominal aortic aneurysm (AAA)
B. Acute aortic dissection
C. Cauda equina syndrome
D. Lumbosacral disk herniation
E. Pancreatitis
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#1
Re: IM 43 mosaabma - 06-11-07 19:26 A. AAA ( back pain, uncontrolled HTN in an Elderly man, non tender, pulsatile mass)
#3
Re: IM 43 jwang - 06-13-07 12:02 I believe the answer is A. if there was a dissection (B) then bp would be dropping (as well as other obvious signs of distress)
#4
Re: IM 43
TheOne - 06-19-07 15:13 The correct answer is A. It is imperative to recognize the potential presence of an abdominal aortic aneurysm (AAA). The combination of the history of hypertension and smoking, the new back pain, and a pulsatile mass on examination is highly suggestive for abdominal aneurysm. The back pain occurs as the expanding mass compresses structures in the retroperitoneum. It is particularly important to make the diagnosis because large aneurysms (greater than 5 cm in diameter) are associated with a very high risk of rupture and subsequent mortality.
Acute aortic dissection (choice B) is the most common aortic catastrophe requiring admission to the hospital, resulting from an extension of an intimal tear in the wall of the artery. The hallmark of acute dissection pain is sudden onset, severe chest and abdominal pain that often radiates from an anterior to posterior direction. The cauda equina syndrome (choice C) is also important to recognize, as it is a neurological emergency. However, it is due to compression of the lower lumbar and sacral nerve roots, and produces sensory loss in a saddle distribution, decreased reflexes, urinary incontinence, and flaccid and weak legs, none of which are present in this case. While lumbosacral disk herniation (choice D) is one of the commonest etiologies of low back pain, the pain is usually described as sharp or lancinating, with radiation from the back down to the legs. Approximately 90% of disk herniations respond to conservative medical management. Pancreatitis (choice E) may also cause dull pain radiating to the back, but the pain is usually excruciating.
#5
Re: IM 43 bingousmle - 06-20-10 08:14 complaint of steady, dull back pain non-tender, pulsatile mass in the epigastric region, blood pressure 170/95 mm Hg points to Abdominal aortic aneurysm
#6
Re: IM 43 babbu5508 - 06-20-10 13:45 A. Abdominal aortic aneurysm (AAA)... non-tender, pulsatile mass in the epigastric region...with uncontrolled hypertension for which he is not using medications regularly
#8
Re: IM 43 bingousmle - 06-30-10 18:01 i think the condition is more common in the abdominal aorta as compared elsewhere due to atherosclerosis which is a high yield concept
#9
Re: IM 43 babbu5508 - 07-10-10 03:27 A. Abdominal aortic aneurysm (AAA)....common in uncontrolled hypertension especially in atherosclerotic vessels...pulsatile mass
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