An 84-year-old man with a lengthy history of smoking survived a small myocardial infarction 2 years ago. He now reports chest and leg pain during exercise. On physical examination, his vital signs are temperature, 37.1deg C; pulse, 81/min; respirations, 15/min; and blood pressure, 165/100 mm Hg. Peripheral pulses are poor in the lower extremities. There is a 7-cm pulsating mass in the midline of the lower abdomen. Laboratory studies include two fasting serum glucose measurements of 170 mg/dL and 200 mg/dL. Which of the following vascular lesions is most likely to be present in this patient?
An 84-year-old man with a lengthy history of smoking survived a small myocardial infarction 2 years ago. He now reports chest and leg pain during exercise. On physical examination, his vital signs are temperature, 37.1deg C; pulse, 81/min; respirations, 15/min; and blood pressure, 165/100 mm Hg. Peripheral pulses are poor in the lower extremities. There is a 7-cm pulsating mass in the midline of the lower abdomen. Laboratory studies include two fasting serum glucose measurements of 170 mg/dL and 200 mg/dL. Which of the following vascular lesions is most likely to be present in this patient?
💡 Explanation
## **Core Concept**
The patient's presentation suggests a condition affecting the arterial system, given the symptoms of chest and leg pain during exercise (intermittent claudication), a history of smoking, and a large abdominal mass. The key here is to understand the relationship between these symptoms and potential vascular lesions.
## **Why the Correct Answer is Right**
The patient's symptoms and physical examination findings, including a 7-cm pulsating abdominal mass, are highly suggestive of an **abdominal aortic aneurysm (AAA)**. The presence of intermittent claudication and diminished peripheral pulses in the lower extremities indicates significant atherosclerotic disease, which is a risk factor for the development of an AAA. The patient's history of smoking and hypertension (blood pressure, 165/100 mm Hg) further supports this diagnosis, as both are major risk factors for AAA. The fasting serum glucose measurements indicating hyperglycemia also point towards diabetes mellitus, another risk factor for atherosclerosis and potentially for AAA.
## **Why Each Wrong Option is Incorrect**
- **Option A:** This option is not provided, but typically, incorrect options might include other types of vascular lesions such as varicose veins, deep vein thrombosis, or arteriovenous malformations, which do not match the patient's presentation of a pulsating abdominal mass and symptoms of arterial insufficiency.
- **Option B:** Similarly, without the specific content of Option B, one might speculate it could involve other vascular conditions like vasculitis or fibromuscular dysplasia, which are less likely given the patient's age, smoking history, and presentation.
- **Option C:** Again, lacking the specifics, one could infer that if Option C suggested a different type of aneurysm or a less common vascular condition, it might not align with the clinical picture provided.
## **Clinical Pearl / High-Yield Fact**
A key clinical pearl is that a palpable, pulsating abdominal mass in a patient with risk factors for atherosclerosis (like smoking, hypertension, and diabetes) is highly suggestive of an **abdominal aortic aneurysm**. Patients with AAA are often asymptomatic until the aneurysm becomes large enough to be palpable or until complications such as rupture occur. Screening for AAA is recommended in high-risk populations.