Answer: Question 1

by Bob Stuntz

Before we answer the question, let’s talk about how to approach these and break them down.  

First, let’s look at the question type.  This is a type 2 question.  Type 1 questions are simple, straightforward questions.  ”What is the recommended door to balloon time in a patient presenting to the ED for STEMI?”  Simple question, simple answer.  Type two questions require a mental leap.  They propose a scenario, require you to come up with a diagnosis, and then ask a question about how to either treat or diagnose that condition without giving you the name of the condition.  So for this question, I clearly want you to think the patient has a AAA.  

This brings me to the question itself.  The exam writers put information in there for a reason, and information is sometimes excluded for a reason.  So let’s go back to my question:

“A 65 year old make with a history of hypertension and a 50 pack year history of smoking presents s/p syncope and abdominal pain.  On exam, his HR is 110/min, BP 82/40, RR 16, and Pox 98% on RA.  You note abdominal tenderness in the midline, and a palpable pulsitile abdominal mass on exam.  What is your next step in the management of this patient?”

He has a history of HTN and smoking, two major risk factors for AAA.  He passed out, complains of abdominal pain, and has a palpable pulsitile mass on exam.  This is their way of telling you he has a AAA without just saying “A patient comes in with a AAA.”  

So now you made the diagnosis.  The question then, based on the answers provided, is what is the best way to make that diagnosis in this patient.  Again, look at the question above.  Your patient is hypotensive (with a history of HTN), and tachycardic.  The answer is easy if you rephrase the question as a Type 1 question:

“What is the best way to diagnose AAA in an unstable patient?”  He is unstable, so CT and MRI are out, and when was the last time you ever did standard arteriography to diagnose AAA?  The answer, of course is bedside US (Choice D). 

Another strategy I find helpful when studying is to think about how the question could be worded differently and how that would change the answer, or if different answers were provided.  What if the patient was stable, and US was not a choice?  What if instead of angiography, one of the answers was “Establish 2 large bore IV’s, volume resuscitate, type and cross for blood and early surgical consultation?”  Think about different ways the question could be phrased.  AAA is a must know for EP’s, so you know you’ll see it.