Item ~?Mark <?

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During a routine office visit, a 62-year-old male is found to have a pulsatile non-tender
mass above his umbilicus. His medical history is significant for hypertension, chronic
renal insufficiency, myocardial infarction, and peripheral vascular disease. He quit
smoking 10 years ago. On physical examination, his blood pressure is 160/90 mm Hg
and pulse is 76/min. Laboratory analyses reveal a serum creatinine of 2.0 mg/dl. Which
of the following is the most appropriate next step in evaluating this patient's abdominal
mass?

o A. Plain abdominal x-ray

o B. CT scan with contrast
0 C. Abdominal ultrasound
0 D. Abdominal MRI
0 E. No testing required

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During a routine office visit, a 62-year-old male is found to have a pulsatile non-tender
mass above his umbilicus. His medical history is significant for hypertension, chronic
renal insufficiency, myocardial infarction, and peripheral vascular disease. He quit
smoking 10 years ago. On physical examination, his blood pressure is 160/90 mm Hg
and pulse is 76/min. Laboratory analyses reveal a serum creatinine of 2.0 mg/dl. Which
of the following is the most appropriate next step in evaluating this patient's abdominal
mass?

A Plain abdominal x-ray [2%)

B. CT scan with contrast [1 3%)

C. Abdominal ultrasound [78%)

D. Abdominal MRI [5%)

E. No testing required [2%)

Proceed to Next Item

Explanation : User ld
This patient's pulsatile abdominal mass is most likely an abdominal aortic aneurysm
(AAA). AAAs are usually asymptomatic and discovered incidentally. AAA rupture is a
potentially life-threatening complication; therefore all incidentally discovered aneurysms
require close follow-up. The imaging modality of choice for diagnosis and follow-up is
abdominal ultrasound, as it has nearly 100% sensitivity and specificity, facilitates
measurement of aneurysm size, and can show the presence of any associated
thrombus. Ultrasound is relatively inexpensive compared to CT or MRI and has the
benefit of not requiring contrast administration.

(Choice A) Plain abdominal films may occasionally incidentally detect AAAs in patients
with calcified aortic walls, but the sensitivity is too low for use as a screening modality.

(Choice B) Drawbacks to CT imaging as compared to ultrasound include higher cost,

Item ~?'Mark <] C> 6j ~~ ~ , 0I[AJ
0. ld : 2717 Previous Next Lab Values Notes Calculator Reverse Color Text Zoom

.; C. Abdominal ultrasound [78%]

D. Abdominal MRI [5%)
E. No testing required [2%]

Proceed to Next Item

Explanation : User ld
This patient's pulsatile abdominal mass is most likely an abdominal aortic aneurysm
(AAA). AAAs are usually asymptomatic and discovered incidentally. AAA rupture is a
potentially life-threatening complication; therefore all incidentally discovered aneurysms
require close follow-up. The imaging modality of choice for diagnosis and follow-up is
abdominal ultrasound, as it has nearly 100% sensitivity and specificity, facilitates
measurement of aneurysm size, and can show the presence of any associated
thrombus. Ultrasound is relatively inexpensive compared to CT or MRI and has the
benefit of not requiring contrast administration.

(Choice A) Plain abdominal films may occasionally incidentally detect AAAs in patients
with calcified aortic walls, but the sensitivity is too low for use as a screening modality.

(Choice B) Drawbacks to CT imaging as compared to ultrasound include higher cost,

requirement for contrast (which would be contraindicated in this patient with chronic renal
insufficiency), and poor visualization of aortic branch origin. CT imaging can add
valuable information when the differential diagnosis of a patient's abdominal pain is
broad, as it provides a better overall examination of the abdomen.

(Choice 0 ) MRI is a poor imaging choice for patients with renal insufficiency given the
association of nephrogenic dermatopathy with gadolinium administration. It is also much
more expensive than ultrasound.
(Choice E) AAA rupture should be suspected in a patient with a pulsatile abdominal
mass, hypotension, and abdominal pain. In this scenario it is appropriate to forego
imaging and emergently send the patient to the OR.
Educational objective:
Abdominal ultrasound is the study of choice for diagnosis and follow-up of abdominal
aortic aneurysms, as it has nearly 100% sensitivity and specificity for this condition.

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