A Noncompliant Construction Worker With a Pulsating Abdomen

Muthunivas Muthuraj; Rahul R. Borra; Panagiotis Iakovidis, MD

Disclosures

November 22, 2021

Physical Examination and Workup

Upon physical examination, the patient appears alert, awake, and oriented. He is not in any distress. Vital signs are as follows:

  • Temperature: 98 °F (36.7 °C)

  • Respiration rate: 16 breaths/min, with a peripheral capillary oxygen saturation of 99% on room air

  • Heart rate: 65 beats/min

  • Blood pressure: 130/70 mm Hg

His height is 70 in (177.8 cm), weight is 168 lb (76.2 kg), and body mass index is 24.11 kg/m2.

Mild to moderate wheezing is noted throughout the bilateral lung fields. Auscultation of the aortic area reveals a systolic crescendo-decrescendo murmur, indicating possible aortic stenosis. Auscultation of the bilateral carotid arteries shows no significant findings, with no bruits or murmurs. The initial abdominal examination reveals no abnormalities. However, a soft bruit is audible on auscultation of the mid-abdominal region. The abdomen is nontender upon percussion. Palpation of the abdominal aorta reveals a widened distal circumference.

The patient is sent for compression ultrasound after the physical examination. Ultrasonography is performed without delay; thus, the patient was not able to fast for the typical 8-12 hours before the imaging.

Figure 1 shows a sagittal image of the abdominal aorta. The dark black circular border is indicative of the abdominal aortic wall. Within the abdominal aorta is a light gray substance that borders the intimal layer of the abdominal aorta, suggesting a thrombotic or atherosclerotic buildup within the vessel. Further measurement of the distal aorta indicates that the diameter of the vessel is 4.4 cm, which confirms the dilation that was palpated on physical examination.

Figure 1.

Figure 2 is the same image as Figure 1, but with a Doppler effect applied. The light gray discoloration within the vessel indicates blood flow. No flow is visible in the area of the suspected thrombus/plaque buildup noted in Figure 1.

Figure 2.

Figure 3 is a transverse view of the middle abdominal aorta. Compared with Figures 1 and 2, Figure 3 shows that the walls of the middle abdominal aorta are not aneurysmal and do not have any thrombotic or atherosclerotic plaque.

Figure 3.

A complete metabolic panel is ordered. The patient's total cholesterol level is 243 mg/dL (reference range, < 200 mg/dL), his triglyceride level is 204 mg/dL (reference range, < 150 mg/dL), and his pancreatic lipase level is 156 U/L (reference range, 10-150 U/L). Although these levels are elevated, they are similar to his baseline values, which were obtained years earlier.

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