Abdominal Aortic Aneurysm

Abstract

MD: A 68-year-old retired draftsman with chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus, and systemic hypertension presented to a hospital emergency department with a 5-day history of worsening dyspnea and abdominal distention and a 1-day history of a nonproductive cough and wheezing. One week earlier he had been discharged from the hospital with a diagnosis of COPD exacerbation, and his prednisone dose had been gradually decreased. His current dyspnea occurred at rest and worsened with minimal exertion. He denied chest pain, abdominal pain, fever, chills, nausea, and vomiting. The patient's father had died of COPD. The patient had an 80-pack/year history of cigarette smoking, drank alcohol occasionally, and denied using illicit drugs. Medications included prednisone (2 mg a day orally), fluticasone propionate, salmeterol xinafoate, ciprofloxacin, guaifenesin, triamterene and hydrochlorothiazide, glipizide, carisoprodol, and home O 2 per nasal canula at 2 L/min. The patient's blood pressure was 137/89 mm Hg; heart rate, 120 beats per minute; and temperature, 36.6°C (97.8°F). He was obese, alert, and oriented and was in moderate respiratory distress, using his accessory respiratory muscles. His extraocular muscles were intact, and his pupils were equal, round, and reactive. His fundi were normal. His oral pharynx contained a whitish plaque on the soft palate. His neck was supple, with no jugular venous distention, lymphopathy, or bruits. He was barrel chested with bilateral wheezing and poor air movement. He had distant heart sounds, without murmur. His abdomen was soft, nontender, and mildly distended. His bowel sounds were normal. A reducible umbilical hernia was present. Neither the liver nor the spleen was enlarged. No abdominal masses were palpated. His extremities were devoid of cyanosis, clubbing, or edema. The pulses were 2+/4+ throughout. Diffuse ecchymoses were present on all extremities. Neurological examination disclosed no abnormalities.His blood glucose was 290 mg/dL, and his leukocyte count was 17 × 10 3 /µL with 82% segmented neutrophils, 3% bands, 8% lymphocytes, and 6% monocytes. His hematocrit was 42%. Room air arterial blood gas showed a pH of 7.31; PCO 2 , 59; PO 2 , 69 (93% saturation); and CO 2 , 29.Electrocardiogram showed sinus tachycardia (105 beats per minute) and low voltage. Chest radiograph showed hyperinflation and chronic changes consistent with COPD, bilateral scarring of the lung bases, some blunting of the left costophrenic angle, and no acute process.