 All right guys, so today I have a case for you and I think you guys will really like it and we're gonna use this case to go ahead and teach a topic so while I'm preparing for residency I thought it would be a good idea to Use my education to go ahead and kind of attempt to teach Let me know if you guys enjoy this kind of format because I continue to make more on a weekly basis So here's the case. We have a 75 year old male that comes to us To the internal medicine service and he comes in originally complaining of fever He complains of a cough And he says he can't really breathe that well So he actually comes to one of our colleagues and they do some work up and they realize that you know He actually just has a basic pneumonia So they're treating him for pneumonia They treat him with some antibiotics and then you happen to be the lucky intern or resident or med student on call When a few days later the nurse calls you in the middle of the night or the middle of the day and says he has some really bad abdominal pain So this is where we are and apologies for any spelling issues In advance, but we have abdominal pain in this patient. So the question is what do we do? You know? We have a patient with abdominal pain What kind of things should you be thinking about as you're walking to go evaluate them? And so let's quickly just give you some insight into his abdominal pain So you likely will not want to know excuse me. You likely want to know where it's happening So it's right in the middle epigastric of his belly You want enough he has any other symptoms. He says yes, I have nausea vomiting You want to know if the pain really goes anywhere? He says not really you also want to know things about you know fevers and We're gonna say change the color here for a second. We're gonna say he doesn't have any fevers And he's not bleeding, you know in his stool. His bowel movements are okay so really all we have is that he has middle pain and Some nausea vomiting. So what should be some of the next things you would be considering in this patient? So, you know other things you may be asking him and just kind of how bad is the pain? There's just her and he says oh, it's 10 out of 10 So it's a big deal, you know, it's the middle of the night So you need to know do you is this serious or is this not so let's you know Let's talk a little bit more about other information. We want to know right where you are the Kind of covering intern resident medical student and this is a new patient to us so we want to know some details and so We're gonna want to know their past medical history And so when you ask the nurse you look at the chart you realize he has hypertension You realize he has kind of all the common things he has diabetes You realize that he has coronary R disease Just lifestyle kind of issues That he has and you want to know kind of is he on taking on any medications? It says yes I take a blood pressure medication take two actually I'm not gonna worry too much about which ones they are. He takes the statin drug so it helps lower his cholesterol for his CAD Sorry about that and then He Will say that's all the medication he takes and then you know, you want to know other things like let's ask about his Social history. What are his lifestyle choices? So he is a smoker long-time smoker But he doesn't drink so no alcohol use I'm just gonna say I'm just gonna say OH Negative, okay, so this is what we have right? We have a 75 year old with abdominal pain pretty bad He has a lot of lifestyle issue with choices takes the medications for and he seems to be Recovering from what he initially came with but he has looks like what seems to be a new problem So you as a doctor, what do you want to do next? And hopefully you are asking to want to learn more about the patient Their vitals are physical exams. So let's talk about their physical exams. So I'm gonna just put that here I'm just gonna say P ex and you know, you do basic heart lungs Abdomen you take their vitals. So let me give you their vitals first. So his blood pressure is about 120 over 70 his heart rate is up He's about in the hundreds and the rest of his vitals are fine you look at his lungs You look at his heart. They're doing okay. But when you look at his abdomen, right? That's what you're really focused about It's just tender everywhere So he has tenderness everywhere But no rigidity this is really the main finding right here and then the other thing that you notice on his vitals is that his pulses So his pulses especially And towards his legs are just diminished. They're just not as strong as the ones in his arms So based off of what I just gave you, you know, looking at all of this What would be kind of what we call your differential diagnosis? so What would be things that you'd be considering about so again, just to paint the picture you have an older man Who has abdominal pain who in the middle some nausea vomiting is pretty severe His physical exam shows that's pretty bad. He has some weird thing going on with his pulses What should be we thinking about so when I think about abdominal pain? First of all, I look at location location really can help you determine a lot of different things So because this is in the middle of the stomach There are certain things that we are more likely to think about than others And if you go down at the bottom of this page, you'll see kind of a nice diagram to show you what type of things You should be thinking about depending on where somebody's pain is so because in the middle We're thinking about things like pancreatitis Sorry about spelling and during the care What other things would be in the middle? So for example, if someone had like a peptic ulcer disease Somebody could have let's see. What else would you expect to have? He could have a ruptured ulcer and then the main question that I love to Kind of hit on and this is what you want to think about as a doctor is what could kill your patient, you know As grim as that is you want to know what's the most important thing You need to be considering every patient with abdominal pain chest pain because you want to make sure you don't miss it So what could kill our patient with middle abdominal pain? Who's older who smokes has history of hypertension and you may be screaming at me while watching this video? But it's a triple A. So this is an aortic aneurysm. Okay an abdominal aortic aneurysm So this is kind of what we're going to be talking about because this is what this case teaches So just to go ahead and be simple. I'm going to go ahead and just kind of erase what we kind of worked on And then we're going to go ahead and teach about a triple A So an aortic aneurysm or a triple A. So let's kind of quickly talk about what that means So your aorta for anyone foreign is basically like your big trung that supplies blood To your body, so it obviously blood comes from the heart And you're gonna have blood that goes down to the lower extremities and then some that go up And so this right here is going to be your aorta. It is kind of like your highway So you're gonna have an aorta that's in your thorax your chest and obviously you're gonna have one of your abdomen So now when you go into your abdomen You have a risk as for many different reasons of developing an aneurysm Which is essentially what I like to consider like a bubble or a pouching. So your wall We're gonna zoom in right here. We're gonna zoom in and this is kind of what we're gonna see when we're zooming in So your wall And here's they order all is made of several different layers. Okay three different layers in fact and Again, you have blood going through it Over time what happens is that the wall gets weaker for many different reasons that we'll talk about But it gets weaker specifically here around the lower abdomen. So that is why you can have a triple A So a couple of reasons that you can have this are things like age, you know, just our heart and our Vessels working against each other for so many years can cause this to weaken. You can have things like smoking, you know smoking just doesn't Work well with the vessels and so you're likely going to damage these walls And so it's going to lead it to be weaker and that's gonna lead the blood to kind of push the vessel outwards So you can have some outpouching going on and other things. Sorry. This is all getting really dirty and messy high blood pressure and other things as well include things like infections. So syphilis Salmonella other infections and we're not going to touch on every single thing But just know that anything that can really cause a weakness in your vessels can also Be a cause for an aneurysm. So should we care like this is a big deal or not So yes, you should care because this is the 13th leading cause of death in the US. I Really have to work on my placement here apologies and That's roughly about 9,000 deaths There's a last stat that I saw on this So it is a big deal and it's also a big deal because pretty silent So our patient, you know came fine We had no issues with abdomen and suddenly all of a sudden we have something going on with a risk of an aneurysm and The aneurysm is not the the problem The problem is you could rupture this wall and your highway that supplies blood Towards your lower extremities your upper extremities can essentially blow open and that's going to lead blood to leak out and avoid having blood going into the other parts of the body so You want to avoid what we call a ruptured AAA Okay, so we talked about risk factors You know, we talked about what we're trying to avoid obviously. It's very serious So how do we kind of identify if our patient this old man supposed to have it? So I'm gonna go ahead and just take a second and let you think about what ways if this patient was yours What would you want to do? And if you said you would want to ultrasound this patient then you are right So ultrasound is super effective I'm not going to throw too many numbers out But sensitivity is a big thing that you'll learn about a medicine if you haven't already and it's basically the idea that if your patient does have The thing you're looking for, you know, how likely is the test going to be positive? Okay, so for An ultrasound it's about like 96 to 98 percent. So It's it's a very good test to identify if it's positive you are likely going to have a AAA and so, you know if our patient had it perfect, but again, remember this happens to a lot of people With these risk factors and so because a triple a can lead to imminent death pretty quickly We actually evaluate people anywhere from like 65 to 75 At least once by just doing an ultrasound if there were a smoker Because we know smoking is such a big risk factor for a triple a so we now we know kind of what to do in terms of identifying it so You know, let's talk about management and that's kind of what we'll end it at So what do you think is going to be our plan for management? What would you do if you were this patient's doctor? So some of you guys may be saying, you know, take them to the operating room and doing surgery Others may have other plans like some just medicine and honestly, they're both right And it really depends on a special number and that number for a triple a is five point five centimeters. So essentially Your aneurysm this thing right here this big baby right there If it's bigger than five point five centimeters You go to surgery because your risk of a rupture on a yearly basis is 11% okay, so that's obviously big enough and then if you're you're smaller than that then we do what we call conservative management so that includes controlling your blood pressure stopping you from smoking and You know causing more issues And just lifestyle choices weight loss Giving them a statin to lower the cholesterol, but that's basically what we do and we keep evaluating it Okay, so that is a big overview on what a triple a is how to evaluate somebody with abdominal pain and the worst-case scenario Which is a rupture triple a that we want to make sure we avoid and our patients are at least are ready to take care of So hopefully you guys enjoyed this video. Hope you guys enjoy this tutorial apologies for all of the kind of mishaps and Marks and spellings and issues But if this was helpful, let me know because I am more than willing to keep doing this on a weekly basis If you guys find it to be advantageous So check out the resources below this video for kind of more Explanations pictures and whatnot and obviously please give me feedback, but thank you guys so much for watching And I'll see you guys in the next one. Take care guys