50yrs old female smoker presented to your clinic referred from other specialty with incidental finding of 4cm infrarenal abdominal aortic aneurysm in her CT that was done to investigate diarrhea .
Q1: Can you highlight key points you want to ask about in the history?
Q2: Since the patient is asymptomatic, will the clinical examination add anything that may affect the management in the future?
Q2: You will need to counsel the patient regarding the diagnosis, can you highlight key point you are going to discuss with patient?
A1 i will ask about patient risk factors like family history -HTN -DM -hyperlipidemia – smoking – trauma -any autoimmune disease like bechet disease – syphilis
A2 its is important to assess patient vital signs for any signs of shock with ruptured AAA
general examination to abdomen to assess pulsating swelling – any ecchymosis – anysigns of peritonitis-pervious scars
examination to LL to asess pulsation -CRT for any showering – pop aneurysm
A3 i will disceuss with the patient his condition and the ways of diagnosis like CTA
and follow up investigation needed every 6 m to follow aneurysm diameter
and possibility of intervention if there is rapid increase in size or signs of ruptures
i will notify thepatient with warning signs that indicated ruptured AAA and the emergency of this condition and possible complication
Q1 HTN,smoking,Autoimmune disease,Abdominal pain and radiation to back,loin pain to exculde renal affection,Constipation,Dirrrrhea,oliguria or polyurea,Anorexia, Claudication symptoms,Sexual dysfunction,Hematemsis or melena,Family Hx (and rupture in 1st degree rralative)
Any vascular (LL ischemia due to assosiated popliteal aneurysm) or abdominal surgery which will affect the typenof intervention
Q2, Pulstile mass, Peripehral ischemia (claudication or restpain),unequal pulse ( assosiated dissection),Renal affection (loin pain), Hyptonsion, all these clincal examination signs warrant mandatory interventi
Q3, Follow up CT aortography is recommended every 6 months to monitor the Size of yhe aneurysm and the progression of symptoma,pathological type of aneurysm
If the patient felt pain radiating to the back it meqns that there is dissection that needa evaluation for intervention
If the patiens felt sudden hypotension ,hematemsis , melena, it may be aortic rupture
Fox sign of retropeitoneal hematoma also means rupture
Q1: i would ask about medical History of HTN , DM , Hyperlipidemia, Ischemic heart Disease .
Life style and other personal habits of medical importance.
History of any Renal manifestations, or Gastrointestinal signs and symptoms.
Q2: Abdominal examination ,clinical Examination is important to Assess Distal perfusion.
And to detect any other aneurysm such as pop A aneurysm.
Q3 : yes ,analysing the complain she had.and will discuss signs and symptoms , Risk factors and importance of follow up by Imaging and examination.
1. Risk factors
DM
HTN
hyperlipidemia
family history
Any symptoms of the aneurysm eg back pain , tenderness
2. Peripheral examination should be done to exclude coexistent peripheral aneurysm
3. Asymptomatic AAA less than 5.5 cm needs surveillance every 1 year by abdominal us
If become symptomatic or increase more than 1 cm per year or ,5 cm per 6 months need intervention
Controlling of any risk factors
Management plan if needs intervention OSR Vs EVAR
Family member examination
Q3: counselling:
as regards to this patient, she has asymptomatic aaa, aneurysm size below the threshold for intervention, so she only needs surveillance.
Q2: specific points on exam.
Q1: the key points in Hx include:
Q1 any abdominal pain , hamaturea , back pain , loin pain , hypotension/ any family history , any knee swellings
Q2 abscent pulses may indicate intervention, presence of popliteal aneurysm may need intervention
Q3 should stop smoking control dyslipedemia if present, control of hypertension if present follow up annually by cta if there is any abdominal pain or back pain come to emergency
Comment for all candidates:
Most of you have given good answers but majority were missing the systematic way:
Q1:
Medical hx: key points:
Surgical Hx:
Family Hx:
Drug Hx:
Social Hx:
Q2:
Exam:
Abdomen:
LL: signs of trash and signs of popliteal aneurysm.
After taking Hx and performing the examination, you should have an idea about the pathology causing the aneurysm whether atherosclerotic or something else.
Q3
Counselling:
A1. I wil ask about any other comorbiditis like hypertension, D.M , hypercholesterolemia
family history of aortic aneurysm
history of previous surgical inerventions or vascular interventions
daily activities and number of cigarrettes per day
A2 . yes clinical examination is important
examination of the abdomen for signs of surgical abdomen as it may be mycotic
aneurysm
examination of both L.L for any other aneurysm or signs of ischaemia
A3 . i will tell the patient to stop smoking
and her case is for follow up every 6 months with C.T aortography or dupplex U\S
tell her with red flag signs of rupture AAA like severe abdominal pain
A1: I’ll ask a more thorough and detailed history (Smoking index, personal habits, other comorbidites like DM, cholesterol and HTN), family history and sexual activity.
A2: Yes,
General examination to know my patient better and provide better care.
Abdominal examination to exclude surgical abdomen.
Distal pulsations to rule out other aneurysms (popliteal, femoral).
A3: I will explain the nature of AAA, and counsel the patients on the risk factors involved (especially smoking and controlling her blood pressure). I’ll also advise the patient on the importance of warning signs like constant back abdominal pain, and a pulsing feeling near her umbilicus.
I will also refer the patient to a gastroenterologist for better management of her diarrhea, and to a radiologist for an ultrasonography every 6 months.
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A1 / i will ask about family hx and daily habits of pt and focused on data from hx about smoking like how many cigarettes per day .
A2 / i think the examination is a corner stone in any vascular case it will make me more oriented and it can make the pt oriented about the symptoms that may be appear later if the case become symptomatic and that will help to reduce the risk of rupture.
A3 / i will discuss with pt the nature of the disease and it is grades , i will discuss the signs and symptoms that will make the pt more oriented and more cooperative . I will discuss with the pt daily habits like smoking and that has a very imp risk factor for make the aneurysm increase in size and rupture. I will discuss the routine imaging every 6 months ( PA U/S ) and for sure it is very important to control the BP of the pt and make it under 130/90 .
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A1 ask about personal habits esp smoking, IV drug use as could be ass with mycotic aneurysm… Hx of present illness: presence of abdominal or back pain , abd distention or constipation — comorbidities as hypertensive or diabetes.
A2 yes given that the abdomen is lax or not , if there’s rigidity on exam , palpation of the aneurysm( pulsation and its size), positive peritoneal signs.
A3 counseling patient is very important for the patient to know his current condition and the and risk factors for the disease for her to stop any modifiable factor as a smoking and to control the blood pressure below 130/80 and for routine follow up every six months by pelvi-Abd ultrasound to comment on the size of the aneurysm and prescence of FF
charting the growth of the aneurysm is important as it can be an indication for intervention there is rapid growth.
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Q1
Asking about siblings, sexual status
Hypertension,dyslipedemia,revurrent attacks of fever , abd pain,haemturia,other cardiac proplems,sense of palpitations or dyspnea
Cludication or ischemic manifestations
Hereditary factors as marfan of fibromuscular dysplasia
Q2
Exam :
Abdominal examination
Pulse exam at both upper lumbs and both lowet limbs
Bp detection at 4 limbs
Water hummer pulse detection
Distal pulse exam at both lower limbs
Q 3
Close observation by us / 6 months
Control BP < 140/89
Antiplatelts
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Q1) I will ask for any history of food poisoning (Salmonella) or any symptoms of salmonella to exclude mycotic aneurysm
medical history : diabetes , hypertension , autoimmune disorders as diarrhea may be due to autoimmune disorder as well
social : smoking
family history of autoimmune disorder or collagen disease like Marfan or Ehler danlos
Q2) general : vital data is crucial like blood pressure and heard rate, fever raise the suspicion of mycotic aneurysm
local : abdominal examination to rule out surgical abdomen
pulse examination to exclude distal showering from the aneurysm and rule out other aneurysm like femoral or popliteal
Q3) I will discuss with the patient her condition that we need to run some tests and if we excluded any other cause of AAA whether salmonella or autoimmune
then she will be on conservative management with PAUS follow up every 6m and tell her about the red flag signs like severe abdominal pain and sudden dizziness and other symptoms related to rupture AAA
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Q1- if the patient heavy smoker , has any cardiac problems , severe abdominal pain & if it is increasing in intensity , lower limb pain or Claudication , loin pain , feeling of abdominal distension , constipation of diarrhea or hypertension
Q2-Even if the patient is asymptomatic, i can continue the examination to see if there is any other aneurysm in other areas thoroughly the body & to assess the prognosis & to be put the patient on plan needed for any future intervention if needed
Q3- I need to counsel the patient that this diameter of anuerysm (4cm & cutoff for in fraternal intervention is 5.5cm) needs no urgent intervention & that the patient is asymptomatic so the patient can just go on a conservative measures with follow-up every 6 months with CT AORTOGRAPHY or duplex
I should ask the patient to cease smoking
To manage the hypertension
To do a check up at other specialities to manage any other medical condition as a preparation for any future intervention if needed .
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A1 history of risk factors ; hypertension – smoking – dyslipidemia – family history
also symptoms of abdominal pain – back pain – lower limb claudication
A2 Clinical examination is important to exclude any other sites of arterial aneurysms ( femoral – popliteal )also distal arterial tree occlusion because of distal embolization from aneurysmal sac or vasculitis
A3-reassurance of the patient as the aneurysm size is small for intervention
but with close follow up of the size and shape of aneurysm every 6 month with sonar also importance to control blood pressure and to stop smoking to avoid complications
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q1 regarding history I want to ask mainly about the risk factors such as smoking, any family history suggesting vascular disease (e.g., Mrfan, Ehler danlos), and other comorbidities; DM..
also I will ask again about symptoms, as the patient may be symptomatic but she is not referring the symptoms to the aneurysm such as abdominal or back pain
q2 yes examination may reveal systemic disease as the hypermobile joints in Marfan and Ehlers danlos, also skin being much stretchy in ehlers danlos
I will check limbs for distal embolization or concomitant vascular disease
finally a general examination to have an idea about the cardiopulmonary reserve, such as blood pressure, signs of COPD or any chest problems
q3 about counselling, I’d like to assure that it’s not for intervention currently, as it’s below the required threshold for intervention (symptomatic or >= 5.5cm), but annual follow up is needed as the risk of rupture increases as the aneurysm grows
if the patient is smoking, therr is need to stop smoking as it increases the risk of aneurysm growth and rupture
I will educate the patient about the symptoms and warning signs that if happens she should seek medical attention immediately
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1-I will focus on smoking history as a strong risk factor for how long and how much per day?
Other factors like family history , Hypertension with aortic dissection sympt , and connective tissue dse as causes of true aneurysm ,
infective endocarditis , IV drug abuse as causes of mycotic aneurysm
It is also might be a pseudoaneurysm dut to blunt trauma , intraarterial instrumentation for coronary dse.
2- OF course on inspection exam obesity, scars of previous explorations , stomas will shift mind to retroperitoneal approach
Palpation of periph pulses:if absent lt UL PULSES might add the possibility of AD
Prescence of Pop A or fem A aneurysms will need repair first
Absence of fem pulses might be patent sciatic artery and iIiac A occlusion may limit EVAR
Abd palp: tender aneurysm may turn the case into emergent repair
3- Discussion about prevelance of diseas in females , its relation with smoking and importance of smoking cessation befoere any intervention and smoking cessation programs
further invest to confirm or exclude the diagnosis especially cta or mra acc to her KFTs and the effect if iv contrast and gadolinium ,
also about Follow up and possible interventions either surgery or endovascular by preop workup regarding her activity on Mets score and her cardiac and respiratory function
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A1 – : i would like to ask about
1- risk factors ; hypertension – smoking – dyslipidemia – family history
2- symptoms of AAA as abdominal pain – back pain – lower limb claudication – syncopal attack
A2 – yes
clinical examination is important to rule out
1- any other sites of arterial tree aneurysms ( femoral – popliteal )
2- distal arterial tree occlusion because of distal embolization from aneurysmal sac
A3-
1- reassurance of the patient as the aneurysm size is not an indication for intervention
2- importance of follow up the size and shape of aneurysm every 6 month with abdominal ultrasound.
3- red flags of AAA complications and when to seek urgent medical advice
4- importance to control blood pressure , dyslipidemia and to cease smoking
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A1: analysis of the main complaint diarrhea; duration, recurrent, numbers per day, consistency, discharge specially bloody diarrhea.
Abdominal pain, pulsation, chest pain or SOB
Other GIT symptoms
PMH like DM HTN IHD renal
PSH for previous abdominal operations and vascular intervention
Family history for inherited diseases or vascular related diseases
Allergy related history
History of medications that could be related to diarrhea
A2: clinical examination is required and could affect the future plan of management
Peripheral pulsations to evaluate lower limb pulsation specifically the femoral for exposure and iliacs to see if the decision for aorto bi fem in open surgical repair for the aneurysm and to be as a reference before the operation for the post op follow up , also to exclude any distal embolic showering as a complication of the aneurysm.
Upper limb bl pressure and pulses if they are equal on both sides to exclude dissection
Abdominal examination for the pulsatile mass and tenderness
Chest examination regarding she is a smoker
A3: after reassurance of the lady, i will discuss the situation for the patient clearly and put a plan including some more investigation like US and CTA of the whole aorta and both lower limbs after KFT to get more anatomical details regarding the size, the neck, the definite size of the aneurysm, the whole aorta must be seen carefully for any arch or thoracic aorta lesions. the patency of the mesenteric, iliacs and lower limb vessels should be examined to exclude any other pathology.
If there is no compliction of the aorta and the aneurysm itself with the size as mentioned in the CT, so conservative measures and follow up after 6 month to see the progress of the lesion and inform the patient that we will follow up with no intervention unless the size becomes 5.5 cm or any complications showed up including limb ischemia, dissection, bleeding, leaking and rupture for which intervention is required.
Inform the lady with warning signs for complications like collapse and sudden acute pain
Advise her to quit smoking and to control her bl pressure
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1- I will ask about
Risk factors:
Smoking…..duration and how many ciggarettes smoked per day.
Hypertension….controlled or not
Diabetes mellitus
Hpercholestrolemia
Social history:
sedentary life style, alcohol consumption
Family history of AAA
History of diarrhea …duration and associated fever.
Medications taken.
2- Clinical examination:
Palpating both CFAs, popliteal arteries and distal pulses to rule out distal showering that could cause ischemia.
Check for possibilty of associated aneurysms in the proximal arteries and popliteal arteries.
Rule out other abdominal pathology.
Clinical examination won’t be significant to add anything since the aneurysm is 4cm and asymptomatic.
3- I need to counsel the patient about the diagnosis.
I will explain to him the nature of the disease, potential risk factors and risk of complications and rupture.
I should be aware that the patient could understand the full info.
Reassurance of the patient is important.
I should tell him about the warning signs and if she feels acute abdominal pain then she sould go to the emergency department to seek medical help.
I should explain that screening and follow up of the aneurysm is important by doing abdominal ultrasound every 6 months for its measurement.
I should discuss ith the patient the treatment options as open repair or endovascular repair.
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1 symptoms : abdominal or back pain or symptoms of embolization in lower limbs , pressure symptoms which is not likely in this case
Medical history especially hypertension
Family history for similar condition
2 sure it will
Abdomen for tenderness or rigidity
Pulsation in the lower limb
3 I will tell her the diagnosis
We should follow up the size of the aneurysm every 3-6 months
We will proceed conservatively in form of risk factors modification but
Intervention will depend on the rate of expansion or reaching the threshold
Intervention will be either by EVAR or open surgery witj their benefits and drawbacks
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Q1: history of hypertension , diabetes mellitus, hypercholesterolemia, constitutional symptoms, any history of diagnosed mesenchymal tissue disorder, or any family member with history of AAA
Q2:full pulse assessment focusing on popliteal pulsations and femoral pulsations for accompanying aneurysmal dilatation
or absent pulsations due to distal showering
Q3:we will do CTA to determine the size and extension of the Aneurysm and to exclude others and if it less than 5cm we will follow up with yearly CTA and life style modification and warning signs (sudden acute pain in the abdomen or in her foot)
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Q1 : Key Points to Ask in the History
it’s important to focus on factors that may influence the risk of AAA rupture and guide management decisions.
Vascular Risk Factors:
Smoking History: Duration, intensity
Hypertension: Presence, duration, and control. Hyperlipidemia: Diagnosis, treatment, and lipid profile. Diabetes Mellitus: Diagnosis, type, and control. Family History: Any history of AAA or other vascular diseases in first-degree relatives.
Symptoms:
Abdominal or Back Pain: Constant or intermittent, radiating or localized. Pulse Deficit: Difference in pulse strength between upper and lower extremities. Peripheral Artery Disease: Claudication, rest pain, or tissue loss in lower extremities. Aortic Dissection: Sudden, severe chest or back pain, often radiating to the extremities.
Social History:
Occupation: Physically demanding jobs may increase the risk of AAA rupture. Lifestyle Factors: Sedentary lifestyle, diet, and alcohol consumption. Medication Use: Any medications that may impact vascular health, such as corticosteroids or anticoagulants.
Q2: Role of Clinical Examination
identifying Associated Conditions: Checking for signs of peripheral artery disease, hypertension, or other vascular disorders. Assessing Abdominal Tenderness: Ruling out any acute abdominal pathology that may mimic AAA symptoms. Palpating the Aortic Pulsation: Although unlikely to be palpable in a 4 cm AAA
However, in this case, the clinical examination is unlikely to significantly impact the immediate management decision, which will primarily be based on the aneurysm size and patient risk factors.
Q3: Key Points for Patient Counseling
When counseling the patient about the diagnosis of an AAA, it’s important to provide clear and concise information, address concerns, and discuss treatment options. Here are some key points to consider:
Explain the Diagnosis: Use simple language to describe what an AAA is and its potential complications, such as rupture.
Assess Understanding: Ensure the patient understands the information and ask open-ended questions to clarify any doubts.
Discuss Risk Factors: Explain how smoking, hypertension, and other risk factors contribute to AAA formation and rupture.
Address Symptoms: Reassure the patient that most AAAs are asymptomatic, but they should be aware of potential symptoms like abdominal or back pain.
Discuss Treatment Options: Explain the various treatment options, including surveillance, open surgical repair, and endovascular repair, along with their risks and benefits.
Encourage Lifestyle Modifications: Emphasize the importance of smoking cessation, blood pressure control, and a healthy diet to reduce the risk of AAA progression.
Address Anxiety and Fear
Reassure the patient that regular monitoring and timely intervention can significantly reduce the risk of complications.
Provide Support and Resources
Refer the patient to support groups or other resources for emotional support and information.
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Risk factors as DM HT cardiac issues any chest problems any positive family history
Clinical examination of distal pulses to rule out any pad or any distal
embolization
If there is any tenderness over aneurysm on palpation as
Will discuss 2 things first educate the pt about her disease and its complications and future needs for any intervention
Second to educate how to modify risk factors that may affect her disease to avoid
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Q1==Only highlights in hsitory
CC/about diarrhea itself was it bloody, associated with abdominal pain , aute or subacute and progressive?, recent fever 🤒
PMH/Active disease like htn, collagen disease, previous surgery specially other site aneurysm , medications ,alcohol intake
FH/ previous aneurysmal member in family
Socio/ where living, nearest hospital type of house , wt doing for living ist stressful?
SR/ ll claudications ,kidney problems , heart problem ?
I yet Don’t know if asking about gyna problems would be relative?
-I think i’ve added things already excluded in article by word “incidental”
Q2== pt may be noncludicant yet with diminished abpi or pulse peripherally or pulse not relative to contralat side
Q3== * that’s dilation of main vessel in body yet not expanded enough or symptomatic for intervention
* pt would need half yearly us for measuring size and comparing to base us
*needs to stop smoking might refer smoking cessation service
*pt would need to avoid long-term stress
*don’t know honestly if pt with aaa go on medications like antiplatelets or anticoagulation but i think 🤔 — logically would need –i would search for this
* should be notified that at any time feeling severe abd pain , abdominal pain associated with drowsiness to reach nearest hospital and mention about aaa , also that she notifies people in daily contact with her to mention that if shocked at any time and for her doctors
*surgical and endovascular ttt are options available for ttt but her stage doesn’t need yet
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Q1.I would like ask about
Any unintentional weight loss
any abd pain and analysis it if found
Any gluteal or thigh or leg pain or short distance cludictation
Is there pain with exercise?
And I would ask about
Previous hospital admissions?
Any previous surgeries in past?
If there is any relative have same concern?
Have any chronic disease?
Any allergies?
Regular medication on it like DM or HTN drugs?
With whome she lives?
What is type of here occupational?
Any special hapits like she is smoking how much packs and scince when she started smoking
Is she drinks alcohol?
Level of activity?
….
Q2.
Yes clinical examination would give me both ll limb condition
If there is absent pulse or parasthesia or motor
Capillary refelling state
To evaluate limbs condition right now
….
Q3.
So I would tell her that she has a pulge on her main blood tube which called aorta
So this pulge is 4 cm
We need further Ct angio on abd aorta and both ll limb to have more information about this concern
But we need to do some labs about kidney function
Then
We would have a regular surveillance by abdomen Al US ever 6 months
if there is any abd pain or L limb pain
Please get contact with us or with her GP
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Q1 / At first I would like to ask about if she had any family history of AAA, also I will ask about any episodes of a bdominal pain., medication history is also important . I will ask about general condition of the patient that may prevent surgical intervention such as cardiac and chest condition .
Q2/. Yes peripheral examination for vasculature is important as distal showering may lead to blue toe syndrome also the assosiaton of other peripheral aneurysms as popliteal aneurysm may be found
Also local andominal exam may add some findings as auscultation of bruit may indicate aortic visceral branches stenosis . Palpation of thrill may be aortocaval fistula . By inspection the presence of flank echymosis means retroperitoneal hematoma which means leaking aneurysm . Also we should not miss. Blood pressure examination which may be due renal artery stenosis if blood pressure is high and also unequal blood pressure in both upper limbs by more then 30 mmHg means subclavian artery pathology and that will affect access site choice later on if brachial access is needed
Q3/. At first I will explain what aneurysm is to the patient what symptoms the patient might experience in the future as compression symptoms ,distal ischemia .
Also I will discuss with patient how we will manage her 4 cm AAA which will be conservative and how will we follow it up which is by duplex US every 6 mothes finally I will discuss with her what are management options if it increases in size or if it ruptured during follow up
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A1: I would get a more detailed history regarding her general condition and medical diseases and her activity in addition to medications and regarding the CT finding I would clarify that she is truly asymptomatic in the form of the absence of abdominal pain,foot distal embolization and claudication pain, absence of any localized other swelling in relation to arterial supply in addition to the back pain and abdominal pain with their nature and possible etiology
A2:to properly evaluate the patient and to exclude any signs of distal ischemia as a result of distal embolization in the form of finding trophic changes patches of toes discoloration, absence of pulsations any other aneurysms either popliteal or femoral as any of above findings might alter the way of management
A3: first I have to explain to her what aneutyrm means then I have to talk to her about the size of it and the threshold for the intervention and the Ct follow-up intervals also i need to illustrate to her the complication and when to come if she suffered from any of the complications. in addition to my advice to her about smoking cessation.
Thank you for your comment, family hx of AAA or rupture AAA in the 1st degree relative is very important and can be an indication to offer repair at size below the threshold.
Asking aout the other risk factors of atherosclerosis e.g HTN, Hypercholesterolemia, DM etc.
Well done couselling about smoking cessation being a strong factor associated with rapid growth of AAA.
Also, hx and examination of the abdomen is improtant to exclude that the aneurysm is tender or rule out hostile abdomen if previous surgery was done, that can change your management in the future when the AAA reaches the threshold so you can offer EVAR instead of open repair.