Question 2
You are a consultant in charge in a tertiary emergency department at 2300 hrs. You overhear a junior medical officer who recently commenced night shift- asking a nursing staff member to arrange the discharge of a 72 year-old man, whom he has diagnosed with renal calculi. Nursing staff express their concerns with you as they state that the patient has ongoing right sided abdominal pain. You have not worked with the medical officer before.
a ) State five steps (5) that you would take in this circumstance. (5 marks)
- Approach the medical officer and tell him that the nursing staff are concerned about this patients discharge
- Ask the registrar whether he has considered the possibility of the patient having a ruptured AAA
- Go and see the patient and examine the patient
- Use ultrasound to check for the presence of a AAA
- Organise further imaging such as CTA to exclude an aortic aneurysm if not viewed with ultrasound )
b. State five (5) limitations to the performance of bedside ultrasound to rule out AAA for this
patient. (5 marks)
- Patient body habitus – obesity
- Patient fasting status – increase the bowel gas overlying the aorta if not fasted
- Patient’s pain and compliance with the exam
- Examining doctors level of credentialing and expertise
- Quality of ultrasound machine image
c ) State four (5) ultrasound features that are consistent with AAA rupture. (4 marks)
- Periaortic haematoma
- Retroperitoneal haematoma
- Visible rupture in the wall of the aorta
- Colour Doppler showing extravasation of blood from aorta into periaortic area
- Intraperitoneal blood
Note that in the vast majority of cases there are no features visible on ultrasound to suggest rupture. It is a clinical diagnosis made in the context of a AAA on ultrasound