Comprehensive Abdominal Aortic Aneurysm (AAA) Case Study

This is not a real patient chart. The names and data have been created.

Patient Chart

Patient Name: John Edward Miller
Date of Birth: 08/12/1954
Age: 70
Gender: Male
Medical Record Number: 20250307
Date of Admission: 03/07/2025
Primary Care Provider: Dr. Jennifer Lawson

Chief Complaint (CC)

"I've been feeling some pain in my abdomen, and it sometimes radiates to my lower back. I think it started a couple of days ago."

History of Present Illness (HPI)

John Miller is a 70-year-old male who presents with complaints of dull, constant abdominal pain that has been ongoing for the past 3 days. The pain is localized to the mid-abdomen and occasionally radiates to the lower back. The pain is described as a "deep ache" that intensifies when standing or walking. The patient denies any trauma, nausea, vomiting, or changes in bowel movements. He also denies any recent weight loss, but reports feeling more fatigued than usual.

The patient has a long-standing history of hypertension and smoking, which are risk factors for vascular disease. He has had a recent history of mild back pain due to osteoarthritis but has not experienced anything like the current abdominal discomfort.

Past Medical History (PMH)

  • Hypertension – diagnosed 15 years ago, managed with Losartan
  • Hyperlipidemia – diagnosed 10 years ago, controlled with Atorvastatin
  • Osteoarthritis – diagnosed 5 years ago, treated with acetaminophen as needed
  • Smoker – 30-pack years (quit 5 years ago)

Surgeries & Procedures

  • Cholecystectomy at age 50
  • Left knee arthroscopy for meniscus repair 8 years ago

Allergies

  • Penicillin – rash

Medications

  • Losartan 50 mg daily
  • Atorvastatin 20 mg nightly
  • Acetaminophen 500 mg as needed for pain

Family History (FH)

  • Father: Deceased at age 75 from myocardial infarction
  • Mother: Deceased at age 80 from stroke
  • Brother: Alive, 65, with hypertension and type 2 diabetes

Social History (SH)

  • Smoking: 30 pack-years, quit 5 years ago
  • Alcohol: Drinks socially (1-2 drinks per week)
  • Drug Use: Denies illicit drug use
  • Occupation: Retired carpenter
  • Living Situation: Lives with wife, adult children visit regularly

Review of Systems (ROS)

  • General: Fatigue, mild weight loss (unintentional)
  • Cardiovascular: Occasional chest discomfort, no palpitations
  • Respiratory: No shortness of breath, no cough
  • Gastrointestinal: Mild abdominal discomfort, no nausea or vomiting
  • Neurological: No focal deficits, no dizziness

Physical Assessment Findings

Vital Signs:

  • Temperature: 98.6°F (37.0°C)
  • Heart Rate: 84 bpm, regular
  • Respiratory Rate: 16 breaths/min
  • Blood Pressure: 145/90 mmHg
  • Oxygen Saturation: 96% on room air
  • Height: 6'1"
  • Weight: 218 lbs.

General Appearance: Alert, appears mildly uncomfortable with abdominal tenderness
Cardiovascular: Regular rate and rhythm, no murmurs, pulses equal in both lower extremities
Abdomen: Mild, non-localized tenderness in the mid-abdomen, no rebound tenderness or guarding, no palpable masses
Neurological: No focal neurological deficits, alert and oriented

Laboratory Results

Basic Metabolic Panel (BMP)

Test Result Reference Range
Sodium (Na) 138 mEq/L 135-145 mEq/L
Potassium (K) 4.1 mEq/L 3.5-5.1 mEq/L
Chloride (Cl) 101 mEq/L 98-107 mEq/L
Bicarbonate (HCO₃) 24 mEq/L 22-28 mEq/L
Blood Urea Nitrogen (BUN) 16 mg/dL 7-20 mg/dL
Creatinine (Cr) 0.9 mg/dL 0.6-1.2 mg/dL
Glucose (fasting) 95 mg/dL 70-99 mg/dL

Complete Blood Count (CBC)

Test Result Reference Range
White Blood Cell Count (WBC) 7.5 x10³/µL 4.0-11.0 x10³/µL
Hemoglobin (Hgb) 14.5 g/dL 12.0-16.0 g/dL
Hematocrit (Hct) 42% 36-46%
Platelets (Plt) 220 x10³/µL 150-450 x10³/µL

Coagulation Profile

Test Result Reference Range
Prothrombin Time (PT) 12.5 seconds 11-13.5 seconds
International Normalized Ratio (INR) 1.0 0.8-1.2
Activated Partial Thromboplastin Time (aPTT) 32 seconds 30-40 seconds

Lipid Panel

Test Result Reference Range
Total Cholesterol 180 mg/dL <200 mg/dL
LDL Cholesterol 110 mg/dL <100 mg/dL
HDL Cholesterol 45 mg/dL >40 mg/dL
Triglycerides 110 mg/dL <150 mg/dL

Imaging and Diagnostics

Abdominal Ultrasound

Findings:

  • Abdominal Aortic Aneurysm (AAA) visualized measuring 5.2 cm in the infrarenal segment, consistent with an asymptomatic AAA.
  • No evidence of rupture or dissection.
  • No other masses or abnormal findings in the abdominal organs.

Chest X-ray

Findings:

  • No acute findings. Heart size is within normal limits.

CT Abdomen (Contrast)

Findings:

  • Confirmed AAA measuring 5.2 cm, with a saccular shape. No signs of dissection or rupture.
  • Mild calcification of the aortic wall.