Clinical Case 2

You are the middle grade/senior. Paramedics arrive at 23.30 hrs, bringing a 65-year-old female patient who is complaining of abdominal pain. The pain started this evening and is a constant, central abdominal pain with no radiation, 7/10 in severity. She is a heavy smoker with a past history of myocardial infarction two years ago, since when she has been in rate-controlled AF. She was initially on warfarin, but following a proven gastro-intestinal bleed this was withdrawn.

On examination, she is a thin lady, clearly in pain, apyrexial, pulse 110 AF and BP 90/55. She is short of breath, saturating at 88 % but chest is clear. The abdomen is generally tender, and an enlarged aorta is suspected. She has scant bowel sounds.

What actions would you take? Drag the steps to the correct position in the list.

You have gained venous access and sent blood for lab tests, including D-dimer and clotting, also cross-matching six units of blood. The results are shown in the table below. You have taken an ECG and this shows AF but is otherwise unremarkable.

An ultrasound of the abdomen has then been performed. This shows a dilated fusiform aortic aneurysm measuring 5.4 cm in antero-posterior diameter, with some saccular irregularities.

Which of the following actions should you take and which should you not take?

There is no reason at this stage to start a broad spectrum antibiotic. The elevated D-dimer and shortness of breath should not lead to a CTPA at this stage. You take arterial blood for gas assay. She is on 28% oxygen. The blood results show:

List four of the differential diagnoses.

Rank the three actions, which were correctly identified in the previous question, in order of priority by dragging them to the correct position in the list.