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Vertebral compression fracture
20%
1/5
Muscle strain
0%
0/5
Herniated disk
Ruptured aortic aneurysm
80%
4/5
Spondylolisthesis
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Even though the patient was lifting when the pain started, the presentation of acute onset back pain and severe hypotension is a ruptured aortic aneurysm until proven otherwise. Abdominal aortic aneurysms (AAA) are generally asymptomatic and can be discovered incidentally on exam or imaging study. As it enlarges, an AAA may cause a pulsatile sensation, back pain, and vague epigastric pain. Upon rupture, AAAs cause severe, tearing abdominal pain radiating to the back and hypotension. Emergent surgery is required. Upchurch and Schaub discuss the management of AAAs, in which ultrasound is the preferred method of screening. US is a cost-effective test when used as a one-time screening test in high-risk patients (men age 65-75 with a smoking history). Repair is indicated at greater than 5.5 cm or growth of more than 0.6-0.8 cm per year. Patients with symptomatic AAAs require urgent intervention. Vu et al. discuss AAA ruptures, which they note result from aneurysm growth and wall weakening. Imaging studies of an AAA rupture may show luminal and extraluminal blood extravasation. Endovascular aneurysm repair (EVAR) is an alternative method of treating ruptured AAAs, compared to the high morbidity seen with open repair. Illustration A shows a CT scan of a ruptured abdominal aortic aneurysm. Incorrect Answers: Answers 1-3,5: These disorders can all present with acute onset back pain but in the setting of hypotension (indicated here by the low blood pressure despite an elevated HR) are less likely.
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