In a 72-year-old smoker with a palpable pulsatile abdominal mass, what is the next appropriate step?

In cases where a 72-year-old smoker presents with a palpable pulsatile abdominal mass, the suspicion for an abdominal aortic aneurysm (AAA) is high. The next appropriate step in management is to obtain an abdominal ultrasound. This imaging modality is non-invasive and allows for quick assessment of the mass, confirming whether it is indeed an AAA and aiding in determining its size and extent.

Ultrasound is particularly favored in this scenario because it is effective at identifying the presence of an aneurysm, differentiating it from other types of masses, and it can be performed relatively quickly, which is crucial given the risks associated with a ruptured aneurysm.

While surgical referral may ultimately be necessary depending on the ultrasound findings, and a CT scan may provide additional detail if the ultrasound is inconclusive, the abdominal ultrasound is the initial and most appropriate immediate step in this acute setting. Starting antihypertensive treatment is generally supportive and important for long-term management but does not address the immediate need for diagnosis and assessment of the mass.