Based on the above information, what are the priority:
Based on the above information:
“I want to understand what is happening with me and then go back to being able to fish without pain.”
Goals left blank for learner to develop
Goals left blank for learner to develop
The plan for this patient is to be referred to the emergency department for additional medical evaluation, including diagnostic imaging to either confirm or disconfirm a suspected abdominal aortic aneurysm (AAA).
1. The patient is a 72-year-old man who presents with low back pain and pulsatile mass, which raises the index of clinical suspicion for AAA. This physical therapy assessment requires referral for additional testing and consultation to confirm, as may be considered medically appropriate. Recommend holding physical therapy at this time pending additional referral and consultation with the emergency department.
4. According to the literature, the pretest probability of AAA is high in this patient secondary to the presence of two main risk factors. The odds ratios associated with male gender and age 70 years are 5.71 (95% confidence interval [CI]; 95% CI: 5.57–5.81) and 14.46 (95% CI: 13.45–15.55) for AAA. This means that (a) men are over 5 times more likely than women to present with AAA and (b) people aged ≥ 70 years are almost 15 times more likely than people aged 50 years to present with AAA. The patient’s previous history of smoking also places him at elevated risk of vascular pathology.
5. AAA are defined as 3.0-cm enlargements of the abdominal aorta. The clinician uses their fingertips to assess the lateral margins of the abdominal aortic pulse, and then the distance is measured as an approximation of the diameter of the abdominal aorta. The advantages of using the fingertips instead of thumbs are (a) broader palpation surface for more patient comfort and (b) a decrease in likelihood of mistaking one’s own digital pulse for the patient’s pulse. Palpation distances may be greater as palpated from the abdomen, because pulsatile waves are transmitted through the abdominal tissues. (Fig. 10.1) Diagnostic ultrasound or computed tomography is required to confirm the diagnosis and characterize the size of an AAA.
6. Palpation to approximate the width of the abdominal aorta demonstrates moderate diagnostic accuracy overall to determine the presence of an AAA. According to Fink and colleagues, palpation yielded sensitivity of 68% (95% CI: 60–76%), specificity of 75% (95% CI: 68–82%), positive likelihood ratio of 2.7 (95% CI: 2.0–3.6), and negative likelihood ratio of 0.43 (95% CI: 0.33–0.56) with respect to diagnostic ultrasound. Sensitivity was increased for larger AAA (> 5.0 cm). In addition to size of the AAA, additional factors that affect diagnostic accuracy of palpation reduce as abdominal girth and abdominal wall stiffness increase.
7. It is safe to palpate a suspected case of AAA; there are no documented cases of dissection related to palpation.
8. The abdominal aorta begins at the diaphragm, generally at the T12 level, and is located to the left of the lumbar spine. The abdominal aorta bifurcates into the common iliac arteries at the level of the umbilicus.
9. AAA affects ~1.1 million older adults in the United States (1.4%). Rupture rates from natural history studies are ~5.3 to 6.3% per year but may be as high as 33%. Rupture rates increase positively with aneurysm size.
10. An aneurysm is a weakness of the arterial wall. There is no universally accepted mechanism for how aneurysms occur, but there are many well-characterized risk factors.
Fig. 10.1 Assessment of abdominal aorta. With the patient lying supine, the clinician stands at the side of the patient. Place fingertips over the epigastrium to determine the presence of a pulse, and with palms down and index fingers on either side of aorta slowly track laterally from the midline. Width of the aorta can be estimated by measurement of the finger distance from one another once the pulse disappears. An abdominal aortic aneurysm (AAA) is defined as 3.0-cm enlargements of the abdominal aorta. (Adapted from Chaikof EL, Dalman RL, Eskandari MK, et al. The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm. J Vasc Surg. 2018;67(1):2–77 e72.)
1. Widened aortic lumen measuring ~5.8 cm.
2. Mural thrombus surrounding the contrast material.
1. Fig. 10.2