Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Aortic Aneurysm


Medical Codes

ICD-9-CM:
441.2 - Thoracic Aneurysm without Mention of Rupture
441.3 - Abdominal Aneurysm, Ruptured
441.4 - Abdominal Aneurysm without Mention of Rupture
441.5 - Aortic Aneurysm of Unspecified Site, Ruptured
441.6 - Thoracoabdominal Aneurysm, Ruptured, Ruptured
441.7 - Thoracoabdominal Aneurysm

Related Terms

  • Abdominal Aortic Aneurysm
  • Aneurysm of the Abdominal Aorta
  • Aortic root aneurysm
  • Descending Aneurysm
  • Dissecting Abdominal Aneurysm
  • Fusiform Aneurysm
  • Saccular Aneurysm
  • Thoracic aortic aneurysm

Overview

© Reed Group
An aortic aneurysm refers to an abnormal, localized blood vessel wall weakness and bulging or ballooning (dilation) in a segment of the aorta. The aorta is the largest artery in the body, beginning above the left chamber (ventricle) of the heart (ascending aorta), curving down (aortic arch), and descending to the chest (descending thoracic aorta) and into the abdomen (abdominal aorta). Depending on the location of the aneurysm, it may be termed a thoracic aortic aneurysm or an abdominal aortic aneurysm (AAA).

Abdominal aortic aneurysms are more common than thoracic aortic aneurysms. Abdominal aneurysms usually occur in the segment of the aorta between the kidneys and the arteries that go to the pelvis and legs (iliac arteries). Thoracic aneurysms occur in the ascending, aortic arch (transverse), or descending segments of the aorta.

Most aneurysms are approximately pea-sized. Aneurysms tend to grow at a rate of 2.21 millimeters per year, although the rate of growth can vary (Sweeting). The likelihood of rupture, which may be fatal, increases as the aneurysm increases in size. As the aneurysm grows larger, it also exerts increasing pressure against neighboring organs and tissues that may result in potentially lethal complications.

Incidence and Prevalence: The yearly incidence of AAA is estimated at 3% to 9% of the general population (Vilalta). Every year over 10,000 Americans die of AAA rupture, and AAA contributes to the death of over 17,000 more (Murphy; Kochanek; Go).

Source: Medical Disability Advisor



Diagnosis

History: Symptoms vary depending on the location and size of the aneurysm, whether rupture has occurred, and whether there are associated effects due to increased pressure or blood leaking into surrounding organs and tissue.

With an AAA, individuals may be without symptoms (asymptomatic) and unaware of the condition. Some individuals may complain of an abnormal, pulsating feeling in the abdomen. Pressure on the lumbar nerves from the aneurysm may cause pain in the lower back.

An individual with a thoracic aortic aneurysm may complain of sudden, severe chest pain, shortness of breath (dyspnea), fainting, pallor, sweating, a bluish tinge around the mouth and on the nail beds (cyanosis), increased pulse rate, leg weakness, or transient paralysis. Individuals may also experience difficulty breathing, a harsh cough, or wheezing. Compression of the esophagus may cause hoarseness or loss of voice.

Individuals experiencing severe, persistent chest, back, or abdominal pain may have an aneurysm that has already ruptured. Additional symptoms indicating that rupture has occurred include low blood pressure (hypotension), weakness, sweating, anxiety, excessive thirst, a fast heart rate (tachycardia), nausea and vomiting, lightheadedness, fainting, dry skin or mouth, or an abdominal mass.

Physical exam: In non-obese individuals who have an AAA, a pulsating mass may be felt when applying light pressure with the fingertips (palpation). Swelling around the navel (umbilicus) may be evident. A soft blowing sound (bruit) may be heard when listening through a stethoscope (auscultation) placed over the aneurysm. This condition rarely causes a diminished peripheral pulse.

In a study of 198 individuals with AAA, 48% were discovered by history and physical examination, 37% during an imaging or x-ray procedure, and 15% at surgery (laparotomy). Of those detected during an imaging or x-ray procedure, subsequent examination showed that 38% could be felt (palpated) in the abdomen, although the aneurysm had been missed on initial examination (Karkos); therefore, thorough clinical examination is extremely important in diagnosing this condition.

With a thoracic aortic aneurysm, the physician may note an increased pulse rate or cyanosis. Auscultation may reveal an abnormal sound between beats when the heart is at rest (diastolic murmur). An abrupt loss of the pulse at the wrist (radial) and the pulse inside the upper thigh (femoral), or wide variations in pulses or blood pressure between the arms and legs may be noted. The individual may appear to be in shock, which is usually associated with low blood pressure, but the upper number of the blood pressure (systolic) is normal or even elevated.

Tests: Abdominal ultrasonography is noninvasive, with high specificity (100%) and sensitivity (95%). Serial ultrasonography examinations permit following the size of an AAA to determine when elective surgery should be performed (USPSTF).

Thoracic aortic aneurysms may be diagnosed incidentally when a chest x-ray is ordered for an unrelated reason. Electrocardiography (ECG) and echocardiography may help identify a dissecting aneurysm of the aortic root.

Computed tomography (CT) or magnetic resonance imaging (MRI) may be useful in the diagnosis of aortic aneurysm. New functional imaging techniques show promise in assessing the risk of rupture, atherosclerotic regions, and predicting aneurysm growth (Hope).

Blood tests may show decreased hemoglobin levels that indicate blood loss from a leaking or ruptured aneurysm, although in the setting of an acute rupture, the blood tests may not show any change.

Source: Medical Disability Advisor



Treatment

If the aneurysm is small and produces no symptoms, surgery does not appear to improve survival and may be delayed; in such case, treatment is directed at slowing the rate of growth of the aneurysm and reducing the risk of aneurysm rupture. Medications called beta-blockers may be taken to reduce the force of blood vessel contractions, thus lowering blood pressure, statins are used to lower cholesterol levels, and individuals who smoke are counseled to quit. Regular physical examinations and ultrasonographic studies are used to detect enlargement that may justify surgical intervention.

A vascular surgeon should be consulted if the aorta is greater than 3 cm in diameter or if any part of the aortic artery is greater than 1.5 times the diameter of an adjacent section. In general, individuals with an AAA smaller than 4 cm should have yearly ultrasonographies to track progress; if the AAA grows larger than 4 cm but smaller than 4.5 cm, twice-yearly ultrasonographies are recommended. Any AAA 4.5 cm or larger should be referred to a vascular surgeon for assessment of the need for timely surgical resection of the aneurysm and replacement or reinforcement of the damaged aortic section with a graft (Kent).

Urgent but not emergency surgical repair is recommended for aneurysms 5 cm or larger or those that are rapidly becoming larger in individuals without other significant medical problems. Elective surgical repair is often considered for aneurysms between 4 and 6 cm.

Surgical repair of an AAA consists of removal of the part of the artery affected by the aneurysm (resection) and restoration of blood flow using a synthetic or composite graft replacement. This procedure is used in emergency as well as elective situations.

Insertion of an endovascular stent-graft may be an option in some cases. A stent is an artificial tube-like device that reinforces the existing arterial wall. The advantage of a stent is that the blood vessel does not need to be excised and blood leakage is less likely, whereas grafts can tear away from the insertion site or leak blood into the abdomen. When a stent is implanted via an endovascular aneurysm repair (EVAR), the surgeon accesses the aorta via a peripheral artery and uses catheters to place the stent internally within the aorta while viewing live x-ray pictures of the site. This allows treatment without open resection or removal of the aneurysm, eliminating the need for general anesthesia.

Rupture of an AAA constitutes an emergency necessitating immediate surgery. Emergency surgery involves the same procedures as in nonemergency situations, to resect the aneurysm and repair the damaged section of the aorta, with the additional need for stabilizing measures. These measures include the administration of medications to lower blood pressure (antihypertensives) or to decrease the force of blood vessel contractions (beta-blockers), oxygen for difficulty in breathing, narcotics for pain relief, fluids directly into a vein (intravenous), and, if necessary, whole blood transfusions.

Source: Medical Disability Advisor



Prognosis

Reducing the risk of rupture by surgical intervention generally allows the individual a good outcome (prognosis). Nonemergency (elective) surgery carries the risk of death in 4% to 5% (USPSTF). If a rupture is imminent or has occurred, as many as half of individuals may die during surgery (Vilalta).

Source: Medical Disability Advisor



Differential Diagnosis

Source: Medical Disability Advisor



Specialists

  • Cardiologist, Cardiovascular Physician
  • Nephrologist
  • Vascular Surgeon

Source: Medical Disability Advisor



Rehabilitation

While individuals are awaiting nonemergency surgery, and following surgery, cardiac rehabilitation programs may be helpful in educating individuals in light exercise that strengthens the heart and lowers blood pressure, while avoiding sudden physical strains that can momentarily increase blood pressure.

Outpatient physical and occupational therapy at a clinic that specializes in cardiac rehabilitation may be warranted for individuals with aortic aneurysm. Cardiac rehabilitation centers offer ECG monitoring of all participants during the exercise sessions. Individuals learn to monitor their pulse and the amount of energy they expend by utilizing a rating of perceived exertion scale.

Occupational therapy addresses any fatigue or shortness of breath that may occur during activities of daily living. This therapy may also teach energy conservation techniques, in which activities of daily living such as meal preparation are broken up into smaller components, thereby making tasks more manageable.

Source: Medical Disability Advisor



Comorbid Conditions

  • Atherosclerosis
  • Connective tissue diseases
  • Diabetes
  • Hypertension
  • Marfan's syndrome
  • Obesity
  • Systemic lupus erythematosus

Source: Medical Disability Advisor



Complications

Complications include rupture of the aneurysm, which can result in significant deficits or even death from blood loss. Complications of surgical repair include stroke, heart attack (myocardial infarction), paralysis (paraplegia) related to decreased blood flow (ischemia) to the spinal cord, kidney (renal) failure related to decreased blood flow through the renal arteries supplying the kidneys, and death.

Source: Medical Disability Advisor



Factors Influencing Duration

Factors that may influence the length of disability associated with an aortic aneurysm include age of the individual, extent of surgical repair necessary, whether the aneurysm ruptures, and the presence of postoperative complications such as heart attack or kidney failure. Disability may be permanent for individuals who perform strenuous physical work or have serious postoperative complications.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Before and after surgery for an AAA, contact sports and activities that require lifting more than 25 pounds or any significant straining should be avoided. Associated atherosclerotic cardiovascular disease involving the heart or legs and causing effort angina and / or claudication may limit activity or require work accommodations in addition to those necessitated by an AAA.

Following open surgical aneurysm repair, individuals may be hospitalized for 4 to 7 days. Full recovery may take 6 weeks to 3 months ("Abdominal Aortic Aneurysm"). Recovery from insertion of an endovascular stent-graft is shorter, with 2 to 3 days of hospitalization; however, the individual will need extra time off for frequent follow-up visits to ensure the graft is functioning normally ("Abdominal Aortic Aneurysm").

Users may find it helpful to read Chapters 1-3 in "Work Ability and Return to Work," which provide a framework for considering the benefits of staying at—or returning to—work. For more information on risk, capacity, and tolerance, refer to "Work Ability and Return to Work," pages 280-281.

Risk: Before any surgical repair, jobs with very heavy work may contribute to progression if blood pressure markedly elevates with work. After successful repair, there are no jobs that would increase the risk of recurrence.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Does individual have high cholesterol?
  • Is individual 65 or older? Has individual smoked cigarettes for longer than 40 years?
  • Does individual have hypertension, atherosclerosis, or a family history of aneurysms?
  • Does individual complain of an abnormal pulsating feeling in the abdomen or constant pain in the lower back, suggesting AAA?
  • Does individual complain of sudden, severe chest pain, shortness of breath, fainting, cyanosis, increased pulse rate, leg weakness, or transient paralysis, suggesting thoracic aortic aneurysm?
  • Does individual have severe persistent chest, back, or abdominal pain?
  • Were clinical findings consistent with the diagnosis of a thoracic or abdominal aneurysm?
  • What abnormalities did the physician note when individual was examined? Was individual in shock?
  • Did blood tests show decreased hemoglobin levels, indicating blood loss? Did a chest x-ray show evidence of a thoracic aortic aneurysm? Did abdominal ultrasonography reveal an aneurysm? Was CT or MRI required?
  • Did individual receive prompt evaluation by a general or vascular surgeon?
  • Had the aneurysm ruptured?

Regarding treatment:

  • Is medical management optimal, or should a second opinion be obtained from appropriate specialists (cardiologist, vascular surgeon, pulmonologist)?
  • If rupture is not imminent, should elective surgery be delayed to allow stabilization of heart and blood vessel disease?
  • Has rupture or imminent rupture necessitated emergency surgery? Did surgery result in any complications such as bleeding? If so, were these addressed and treated?

Regarding prognosis:

  • Was the surgery uncomplicated?
  • Considering the severity of symptoms and the health status of individual, what was the expected outcome?
  • Did the aneurysm rupture prior to surgery? If so, did individual experience any complications associated with the rupture and surgical repair, such as stroke, heart attack, paralysis, or renal failure?
  • Were these complications addressed in the treatment plan?
  • Has individual received medical consultation by the appropriate specialists (cardiologist, neurologist, nephrologist)?
  • Have the complications contributed to any permanent disabilities?

Source: Medical Disability Advisor



References

Cited

"Abdominal Aortic Aneurysm." Cleveland Clinic. Jan. 2011. Cleveland Clinic. 7 Apr. 2014 <http://my.clevelandclinic.org/disorders/aneurysms/hic_abdominal_aortic_aneurysm.aspx>.

Go, A. S. , et al. "Heart Disease and Stroke Statistics--2013 Update: A Report from the American Heart Association." Circulation 127 (2013): e6-e245.

Hope, M. D., and T. A. Hope. "Functional and Molecular Imaging Techniques in Aortic Aneurysm Disease." Current Opinion in Cardiology 28 (2013): 609-618.

Karkos, C. D., et al. "Abdominal Aortic Aneurysm: The Role of Clinical Examination and Opportunistic Detection." European Journal of Vascular and Endovascular Surgery 19 (2000): 299-303.

Kent, K. C. "Screening for Abdominal Aortic Aneurysm: A Consensus Statement." Journal of Vascular Surgery 39 (2004): 267-269.

Kochanek, K. D. "Deaths: Final Data for 2009. National vital statistics reports." NCHS Advance Data 60 3 (2009): None.

Lederle, F. A. "The Rise and Fall of Abdominal Aortic Aneurysm." Circulation 124 (2011): 1097-1099.

Lederle, F. A., et al. "The Aneurysm Detection and Management Study Screening Program: Validation Cohort and Final Results. Aneurysm Detection and Management Veterans Affairs Cooperative Study Investigators." Archives of Internal Medicine 160 (2000): 1425-1430.

Murphy, S. L., et al. "Deaths: Final data for 2010. National vital statistics reports." NCHS Advance Data 61 4 (2010): None.

Pande, R. L., and J. A. Beckman. "Epidemiology and Prognosis of Aortic Aneurysms." Vascular Medicine: A Companion to Braunwald's Heart Disease. Eds. Mark A. Creager, Joshua A. Beckman, and Joseph Loscalzo. W.B. Saunders, 2012. None-None.

Sweeting, M. J., et al. "Meta-Analysis of Individual Patient Data to Examine Factors Affecting Growth and Rupture of Small Abdominal Aortic Aneurysms." British Journal of Surgery 99 (2012): 655-665.

Talmage, J. B. , J. M. Melhorn, and M. H. Hyman, eds. Work Ability and Return to Work, AMA Guides to the Evaluation of. Second ed. Chicago: AMA Press, 2011.

Talmage, J. B. , J. M. Melhorn, and M. H. Hyman, eds. Work Ability and Return to Work, AMA Guides to the Evaluation of. Second ed. Chicago: AMA Press, 2011.

United States Preventive Services Task Force. "Screening for Abdominal Aortic Aneurysm: Recommendation Statement." Annals of Internal Medicine 142 (2005): 198-202.

Vilalta, G., et al. Biomechanical Approach to Improve the Abdominal Aortic Aneurysm (AAA) Rupture Risk Prediction, Aneurysm. InTech, 2012. In Tech Open. 29 Aug. 2012. InTech. 7 Apr. 2014 <http://www.intechopen.com/books/aneurysm/biomechanical-approach-to-improve-the-abdominal-aortic-aneurysm-aaa-rupture-risk-prediction>.

Source: Medical Disability Advisor