Clinical Vignette II

• Which of the following is the most appropriate next step in management of this patient?

A 61-year-old male presents to the Vascular Surgery Clinic as a new patient after being referred by a local primary care provider for further evaluation of an abdominal aortic aneurysm found during routine physical exam two weeks ago. The patient just recently moved to the Northeastern U.S. area from south Florida to be closer to his family and is still trying to settle down in his new life and home. Due to all of the simultaneously ongoing events associated with the long move, he was unable to make an appointment to see and establish a new primary care provider in the local area until two weeks ago.

The patient states that he was not able to reliably establish a sole primary care provider in south Florida because the Veterans Affairs Medical Center that he went to for medical care seemed to continually change health care providers each time he went in for an appointment. He also states that the last time he saw a physician at the Veterans Affair Medical Center was about a year ago and the last time a physician performed a thorough physical exam was at least over three years ago. He then states that this is the first time that any health care provider has made any mention of an abdominal aortic aneurysm.

According to the electronic medical record notes made by the patient’s new primary care provider two weeks ago, the abdominal aortic aneurysm is a palpable, non-tender, midepigastric, pulsatile mass. It is noted that the patient denies any chest, abdominal, or back pain associated with the newly discovered physical exam finding. It is also noted that the new primary care provider was ill-equipped to perform any additional clinically indicated imaging studies to further evaluate the abnormal physical exam finding at the time of the appointment but strongly advised the patient to see a Vascular Surgeon as soon as possible and even placed a priority referral to several Vascular Surgeons in the area. In addition, the new primary care provider ordered a battery of laboratory testing to be performed. Per the patient’s electronic medical records, the laboratory testing results reveal the following:

Fasting glucose:  normal

Comprehensive metabolic panel:  normal

Complete blood count:  normal

Liver function tests:  normal

Renal function panel:  normal

Hemoglobin A_1c:  normal

Thyroid-stimulating hormone:  normal

Urinalysis:  normal

Urinary albumin-to-creatinine ratio:  normal

Electrocardiogram:  normal sinus rhythm, no significant ST-segment or T-wave abnormalities

Fasting Lipid Panel
Cholesterol                        228 mg/dL (abnl)        130 – 200 mg/dL            

Triglycerides                    211 mg/dL (abnl)        10 – 150 mg/dL              

Direct HDL                         41 mg/dL                           40 – 90 mg/dL                 

non-HDL                             187 mg/dL (abnl)        0 – 160 mg/dL                 

LDL (calculated)             145 mg/dL (abnl)        0 – 130 mg/dL                 

Cholesterol/HDL             5.5 Ratio (abnl)            0.0 – 4.5 Ratio                  

The patient’s medical history is significant for hypertension, hyperlipidemia, and osteoarthritis of bilateral knee joints. His current medications are lisinopril, simvastatin, low-dose aspirin, acetaminophen as needed for knee pain, and a daily multivitamin. He drinks two to three cans of beer almost daily for the past ten years and smokes about one pack of cigarettes daily for the past twenty years. He denies any known family history of early heart disease, abdominal aortic aneurysms, transient ischemic attacks, cerebrovascular accidents, or connective tissue diseases.

On physical examination, temperature is 98.3°F (36.8°C), blood pressure is 150/84 mm Hg, pulse rate is 82 beats/min, respiration rate is 16/min, and oxygen saturation is 97% breathing ambient air. Body mass index is 23 kg/m². Palpation of the midepigastric region reveals a non-tender pulsatile mass. The remainder of the physical examination is unremarkable.

• Initial imaging of the patient’s abdominal aortic aneurysm reveals it to be fusiform-shaped and infrarenally located with a maximum measured diameter of precisely 4.36 cm. Which of the following would be the least appropriate next step in management of this patient?

On physical examination, vital signs are normal. Body mass index is 22.2 kg/m². Palpation of the midepigastric region still reveals a non-tender pulsatile mass. The remainder of the physical examination is unremarkable. Which of the following is the most appropriate next step in management of this patient?

• The now 62-year-old male presents to the Vascular Surgery Clinic for a twelve month follow-up evaluation of his newly discovered infrarenal abdominal aortic aneurysm which measured precisely 4.15 cm in diameter on initial imaging. The patient states that he has cut back significantly on both his alcohol consumption and the number of cigarettes he smokes daily. He states that he was able to make an appointment with his new primary care provider a few days after his first visit to the Vascular Surgery Clinic to address his issues regarding smoking, alcohol consumption, cholesterol reduction, and maximizing tight blood pressure control. He also states that he has been eating healthier, started a light cardiovascular exercise program, and has been taking the prescribed medications as directed for blood pressure and cholesterol management. The patient denies any chest, abdominal, or back pain since his last visit to this clinic twelve months ago and reports feeling very well and has no complaints. According to electronic medical records, the patient had laboratory testing ordered by his new primary care provider just a few days ago which reveals the following:

Fasting Lipid Panel
Cholesterol                111 mg/dL (abnl)        130 – 200 mg/dL

Triglycerides            88 mg/dL                           10 – 150 mg/dL

Direct HDL                 40 mg/dL                           40 – 90 mg/dL

non-HDL                     73 mg/dL                           0 – 160 mg/dL

LDL (calculated)     53 mg/dL                           0 – 130 mg/dL

Cholesterol/HDL     2.8 Ratio                              0.0 – 4.5 Ratio

• Follow-up imaging of the patient’s infrarenal abdominal aortic aneurysm reveals that its diameter has increased since his initial evaluation twelve months ago when its maximum measured diameter was precisely 4.36 cm. Which of the following imaging findings would be a clear clinical indication for surgical intervention in this 62-year-old male patient?

• Follow-up imaging of the patient’s infrarenal abdominal aortic aneurysm reveals that its diameter has increased by precisely 67 mm since his initial evaluation twelve months ago when its maximum measured diameter was precisely 4.36 cm. Which of the following is the most appropriate next step in management of this patient?