A 75-year-old man comes to the emergency room with a history of sudden onset of pain in the abdomen and back. He is found to be hypotensive, with a pulsatile, tender abdominal mass.
Which of the following best describes the correct immediate management of this patient?
Correct Answer A: Abdominal aortic aneurysms (AAA) are aneurysms that occur in the part of the aorta that passes through the abdomen (abdominal aorta). Abdominal aortic aneurysms may occur at any age but are most common among men aged 50 to 80 years. Abdominal aortic aneurysms tend to run in families and to occur in people who have high blood pressure, especially those who also smoke. About 20% of abdominal aneurysms eventually rupture.
Rupture is accompanied by the abrupt onset of back and abdominal pain, abdominal tenderness, the presence of a palpable pulsatile mass, hypotension, and shock. Of note, a ruptured aneurysm may mimic other conditions, including abdominal colic, renal colic, diverticulitis, and gastrointestinal hemorrhage. Not surprisingly, more than 25% of patients presenting with rupture or expansion of an aortic aneurysm are initially misdiagnosed.
Patients with impending or actual rupture must be managed as a surgical emergency (choice A) in a manner similar to that used for patients with major trauma. Such patients rapidly develop hemorrhagic shock, manifested by peripheral vasoconstriction, hypotension, mottled skin, diaphoresis, oliguria, disorientation, and cardiac arrest. Patients with retroperitoneal rupture may show evidence of hematomas on the flank and in the groin. Although rare, rupture with erosion into the duodenum may present as massive gastrointestinal hemorrhage.
A 70 year old man presents to the clinic complaining of steady, dull back pain over the past 3 weeks. 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 170/93 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?
Correct Answer 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.
A 70 year old white male has a slowly enlarging, asymptomatic abdominal aortic aneurysm. You should usually recommend surgical intervention when the diameter of the aneurysm approaches:
Correct Answer C: Based on recent clinical trials, the most common recommendation for surgical repair is when the aneurysm approached 5.5 cm in diameter. Two large studies, the Aneurysm Detection and Management (ADAM) Veteran Affairs Cooperative Study, and the United Kingdom Small Aneurysm Trial, failed to show and benefit from early surgery for men with aneurysms less than 5.5 cm in diameter. The risk of aneurysm rupture were 1% or less in both studies, with a 6 year cumulative survivals of 74% and 64%, respectively. Interestingly, the risk of aneurysm rupture was four times greater in women, indicating that 5.5 CM may be too high, but a new evidence-based threshold has not yet been defined.
A 25-year-old gang member arrives in the emergency department with multiple gunshot wounds to the chest and abdomen. He has labored breathing and is cyanotic, diaphoretic, cold, and shivering. He is wide awake, and in a normal tone of voice he tells everyone that he is going to die. An initial survey reveals a blood pressure of 60/40 mm Hg. His pulse is 150/min and barely perceptible. He is in obvious respiratory distress and has big distended veins in his neck and forehead. His trachea is deviated to the left, and the right side of his chest is hyperresonant to percussion, with no breath sounds.
Which of the following is the most appropriate initial step in management?
Correct Answer D: This patient obviously has a tension pneumothorax on the right. The pressure needs to be relieved immediately, which insertion of a needle will do. Then, a formal chest tube should be inserted. Blood gases or chest x-ray films are not needed to recognize the presence of a tension pneumothorax. These two studies will soon be done in this patient, but not before action is taken to save his life by prompt decompression of the tension pneumothorax. A patient who is awake and alert and speaking with a normal tone of voice has a patent airway. At this moment, he does not need endotracheal intubation, although given his multiple injuries, he will probably end up having surgery and being intubated for that anesthetic.
A patient who presents with pain or fullness in the ear aggravated by chewing most likely has which one of the following?
Correct Answer D: Symptoms of temporomandibular disorders include headaches, tenderness of the chewing muscles, and clicking or locking of the joints. Sometimes the pain seems to occur near the joint rather than in it. Temporomandibular disorders may be the reason for recurring headaches that do not respond to usual medical treatment. Other symptoms include pain or stiffness in the neck radiating to the arms, dizziness, earaches or stuffiness in the ears, and disrupted sleep.
People with temporomandibular disorders have difficulty opening their mouth wide. For example, most people without temporomandibular disorders can place the tips of their index, middle, and ring fingers held vertically in the space between the upper and lower front teeth without forcing. For people with temporomandibular disorders (with the exception of hypermobility), this space usually is markedly smaller.
50% of patients with a TMJ disorder notice ear pain but do not have signs of infection. The ear pain is usually described as being in front of or below the ear. Often, patients are treated multiple times for a presumed ear infection, which can often be distinguished from TMJ by an associated hearing loss or ear drainage (which would be expected if there really was an ear infection).
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