Abrupt Abdominal PainHPI:C.B, a as long as mer heavy smoking 69 yo M with a h/o hyperten

Abrupt Abdominal PainHPI:C.B, a as long as mer heavy smoking 69 yo M with a h/o hyperten www.phwiki.com

Abrupt Abdominal PainHPI:C.B, a as long as mer heavy smoking 69 yo M with a h/o hyperten

Moore, Don, News Director has reference to this Academic Journal, PHwiki organized this Journal Abrupt Abdominal PainHPI:C.B, a as long as mer heavy smoking 69 yo M with a h/o hypertension in addition to COPD presents to the ED with sudden onset abdominal, lower back in addition to R flank pain that started 45 min ago while at home watching TV. He also c/o feeling ‘dizzy’ in addition to some nausea at the time. He denies LOC, chest pain, dyspnea, vomiting, difficulty urinating or blood in his stool. He has not ever had a pain like this be as long as e. The pain was a 9/10 initially, but is about a 6/10 after taking some Tylenol at home. His dizziness in addition to nausea are improved at this time.ROS:HEENT: denies headache, visual changesCV: no chest painResp: denies dyspnea, chronic coughGI: Midline, peri-umbilical abdominal pain, nausea w/ pain initially, denies vomiting, diarrhea in addition to blood in stoolGU: no dysuria, hematuriaExt: denies leg pain, Some R flank in addition to lower back painNeuro: no LOC or weakness

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PMHx: COPD, Hypertension, HyperlipidemiaPSHx: appendectomy at age 20, ‘had a normal colonoscopy’ 3 years agoMedications: Spiriva, Metoprolol in addition to hydralazine, simvastatin, Fish oil in addition to daily multivitaminSocHx: Former 50 year 2 pack/day smoking history, has been smoke free as long as 6 monthsModerate alcohol useDenies recreational drugsMarried, retired truck driverFamHx:Mother – had hypertensionFather – depressionBrother – hypertension in addition to ‘some surgery as long as an aneurysm’Physical ExamGen: mild distressHEENT: NCAT, PERRL, EOMICV: RRR, no r/m/g, 2+ radial in addition to dorsal pedis pulsesPulm: CTA, regular respirationsAbd: mild peri-umbilical tenderness to palpation, pulsatile mass Ext: normal strength, no CVA tendernessSkin: no rashes or lesionsNeuro: A&Ox3, no focal neuro deficitsDifferential Diagnosis

Per as long as ated viscusPancreatitisAbdominal Aortic Aneurysm (AAA)Urinary CalculiBowel obstructionMusculoskeletal painDDx:What would you order nextLabsVitalsUrineHemoccultCBC Coagulation studiesCMPLipase in addition to amylaseImagingPlain radiographyAbdominal UltrasoundAbdominal CT w/ in addition to w/o contrast if stable

ResultsLabsVitals – 100/60 115 37.5 97% on RAUrine – normalHemoccult – negativeCBC 14 8.0 200PT/INR in addition to PTT all normalCMP – 140/ 4.0/ 100/ 24/ 15/ 1.0 / 95Lipase 25, Amylase 50, ALT 25, AST 35Bedside Abdominal UltrasoundImaging: Bedside US

Imaging: Bedside UShttp://www.meddean.luc.edu/lumen/MedEd/Radio/curriculum/Surgery/aneurysm2.htmAbdominal CT http://www.medscape.com/content/2004/00/47/08/470838/470838-fig.htmlDiagnosis

Abdominal Aortic Aneurysm (AAA)Bedside Abdominal US shows AAA 6.0 cm in diameterConfirmed with Abdominal CT with contrastTreatmentC.B. is started on IVFs, given 02 by nasal cannula in addition to vascular surgery is consultedBecause of the sudden onset of pain, size of aneurysm, hypotension in addition to feeling ‘dizzy’, there is concern C.B.’s AAA may be rupturing.He is admitted to vascular surgery as long as stabilization in addition to urgent AAA repair.Abdominal Aortic Aneurysm

PresentationFlank, back or abdominal painsevere in addition to abrupt onset, 50% describe pain as a ripping or tearingGI bleedingSyncope (10%)Extremity ischemia from embolization of a thrombusShock: hemorrhagic Sudden deathAtypical presentations may complicate the diagnosis:Flank, groin or isolated quadrants of abdominal painNausea, vomitingBladder painHip painTenesmusDiagnosis Physical Exam:Palpable abdominal mass (only present in 2%)Tender abdomenHypotensionDecreased femoral pulsesLook as long as peri-umbilical ecchymosis (Cullen sign) or flank ecchymosis (Grey Turner sign), which indicate acute ruptureLabs: H&H may not be affected

Treatment/ManagementSymptomatic AAAs require an emergency vascular surgical consult as long as repairConcurrent stabilization with IVFs, O2 in addition to bedside diagnosis with US (>90% sensitive as long as demonstrating presence in addition to measuring diameterClassic triad of symptom: abdominal in addition to /or back pain, a pulsatile abdominal mass, in addition to hypotension only occur in ~1/3 of patients with ruptured AAAs.Non-symptomatic AAAs Prompt outpatient referral to vascular surgeon in addition to BP control. AAAs between 4-5cm in diameter are associated with a 1% per year risk of rupture, monitoring every 6 months with US or CT scans.Any Aneurysm >5.5cm in diameter should be repaired.Gross Pathology – AAAGross Pathology – Ruptured AAA

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Microscopic Images – AAAA microscopic image of the abdominal aortic aneurysm shows intense inflammatory change in addition to fibrosis in the adventitia (H in addition to E, original magnification ×40). InflammationFibrosisInflammatory cells are mainly lymphocytes, plasma cells, in addition to eosinophils (H in addition to E, original magnification ×400).Microscopic Images – AAAObliterative phlebitis is observed (EvG, original magnification ×200)Microscopic Images – AAA

Immunostaining of IgG4 reveals numerous IgG4-positive plasma cells within the lesion (immunostaining of IgG4, original magnification ×400).Microscopic Images – AAABedside USBedside US

Imaging: Plain radiographyhttp://www.meddean.luc.edu/lumen/MedEd/Radio/curriculum/Surgery/aneurysm2.htmCT without IV contrast Ruptured Abdominal Aortic Aneurysm an abdominal aortic aneurysm (A) with high density blood (arrows) indicating rupture. http://www.meddean.luc.edu/lumen/MedEd/Radio/curriculum/Surgery/aneurysm2.htmReferences:Prince LA, Johnson GA. Chapter 63. Aneurysms of the Aorta in addition to Major Arteries. In: Tintinalli JE, Stapczynski JS, Cline DM, Ma OJ, Cydulka RK, Meckler GD, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York: McGraw-Hill; 2011. http://www.accessmedicine.com/content.aspxaID=6359748. Accessed November 6, 2012.Elefteriades JA, Olin JW, Halperin JL. Chapter 106. Diseases of the Aorta. In: Fuster V, Walsh RA, Harrington RA, eds. Hurst’s The Heart. 13th ed. New York: McGraw-Hill; 2011. http://www.accessmedicine.com/content.aspxaID=7836581. Accessed November 7, 2012.Images from http://www.meddean.luc.edu/lumen/MedEd/Radio/curriculum/Surgery/aneurysm2.htmYasushi Matsumoto, Satomi Kasashima, Atsuhiro Kawashima, Hisao Sasaki, Masamitsu Endo, Kengo Kawakami, Yoh Zen, Yasuni Nakanuma, A case of multiple immunoglobulin G4–related periarteritis: a tumorous lesion of the coronary artery in addition to abdominal aortic aneurysm, Human Pathology, Volume 39, Issue 6, June 2008, Pages 975-980, ISSN 0046-8177, 10.1016/j.humpath.2007.10.023. (http://www.sciencedirect.com/science/article/pii/S004681770700576X) Keywords: IgG4; Autoimmune pancreatitis; Retroperitoneal fibrosis; Aneurysm; Arteritis

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