October 27, 2010

PLAB Question 20

A 60 year old patient presents with three days onset of severe abdominal pain radiating to the back. On physical examination, a pulsatile mass in the periumbilical region is found. The patient is hemodynamically stable.

The next most appropriate step would be:

a) serum glucose
b) oral cholecystogram
c) liver biopsy
d) intravenous urogram
e) endoscopy
f) CT scan of the abdomen
g) blood culture
h) serum alcohol level
i) serum amylase
j) ultrasound of the abdomen








ANSWER
The correct answer is F



Explanation
When patients have the classic triad of pain, hypotension, and a pulsatile abdominal mass, the diagnosis of ruptured Abdominal Aortic Aneurysm(AAA)is straightforward and is usually made rapidly. However, many patients do not present classically, and misdiagnosis of ruptured AAAs, which leads to a delay in definitive surgical therapy, is very common.

Patients who are misdiagnosed are usually hemodynamically stable on presentation but are at risk for sudden and catastrophic deterioration.

Because patients with ruptured AAAs usually have abdominal, back, or flank pain, with or without hypotension, common misdiagnoses are other disease processes causing these symptoms.

The sudden onset of pain often leads to the clinical suspicion of renal colic. Abdominal pain and tenderness may suggest pancreatitis, intestinal ischemia, or other intraabdominal disorders. The diagnosis of musculoskeletal back pain is especially dangerous because such patients are often discharged from the Emergency Department.

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