A 63-year-old woman comes to the emergency department complaining of severe midabdominal pain. She reports that the pain has increased in intensity over the past few days. There has been no associated nausea or vomiting, no change in bowel habits, and no relief afforded by position changes. She is postmenopausal and does not take hormone replacement therapy. She has a 30-year history of hypertension, and has been noncompliant with her therapy of calcium channel blocker and thiazide diuretic. On examination her abdomen is obese but there is a suggestion of a nontender, pulsatile mass in the epigastric region. The remainder of the physical examination is normal. Which of the following is the best next step in management?
| A. Abdominal ultrasound |
| B. Abdominal CT scan without contrast |
| C. Abdominal CT scan with contrast |
| D. Angiography |
| E. Observation |
Filed under: USMLE STEP III QUESTION BANK, USMLE Test Prep | Tagged: ARCHER GASTROENTEROLOGY, archer surgery, usmle step 3 surgery |
Archer USMLE Step 3 Blog 
CT abdomen with contrast
CT abdomen with contrast
Abd. Ultrasound sounds à reasnsnle next step
Abdominal ultrasound….
A
C. Abdominal CT scan with contrast
A
C pt is obese so usd is not effective to rule out AAA
my 2 cents
Fast scan us
A
Because aneurysms tend to increase in diameter with time, patients who are identified with having aortic aneurysms are serially followed up with ultrasound. Patients who have abdominal aortic aneurysms (AAA) are typically asymptomatic and these aneurysms are typically identified as incidental findings. If a patient is symptomatic, the most common symptoms are back and abdominal pain. If rupture occurs, patients are at high risk for death (about 90% mortality with rupture) and patients are immediately taken to the operating room for surgical repair. Elective repair is indicated for symptomatic patients or asymptomatic patients if the diameter reaches 5.5 cm (men) and 5.0 cm (women). The larger the diameter of the abdominal aorta, the more likely the aneurysm will rupture, which is why elective repair is warranted.
Abdominal aortic aneurysms larger than 5 cm have greater than a 30% chance of rupturing in 3 years. As most ruptures result in death, and as the mortality of surgical repair has fallen sharply, surgical repair of the aneurysm is indicated. Aneurysms that are not repaired expand on average at about 0.4 cm per year. Repair of these aneurysms can be accomplished via either traditional open approaches or new endovascular approaches.