A 21-Year-Old Man With Epigastric Pain After a Wild Party

Abraham A. Ayantunde, MB BS, FRCS; George G. Araklitis, MB BS, BSc

Disclosures

February 25, 2019

Physical Examination and Workup

Upon examination, he appears to be alert, comfortable, and in no acute distress. He is well oriented to person, time, and place. His vital signs reveal a heart rate of 76 beats/min, a respiratory rate of 18 breaths/min, and an O2 saturation of 97% on room air. His temperature is normal. His respiratory and cardiovascular examinations reveal no abnormal findings.

The abdominal examination reveals no abnormal findings on inspection, except for a well-healed appendectomy scar; otherwise, the abdomen is scaphoid and without any discoloration, bruises, or visible abnormalities. Palpation reveals a slightly tender but otherwise soft epigastrium, with positive bowel sounds and no evidence of guarding or rebound tenderness. No masses or organomegaly are appreciated, and the abdomen is resonant to percussion, with the absence of a fluid wave or shifting dullness. The spleen and liver margins are normal and the kidneys are not palpable.

Neurologic examination is grossly normal with equal power, tone, and bulk in both upper and lower extremities bilaterally, normal reflexes, and intact cranial nerves. His mental status examination findings are normal.

Laboratory investigations reveal a hemoglobin count of 16.9 g/dL (169 g/L) and a white blood cell count of 7.8 × 103/μL (7.8 × 109/L). Urea and electrolytes are within normal limits, and no derangement of liver function is noted. Serum amylase findings are normal. A chest x-ray shows clear lung fields, a normal heart size, and no evidence of air under the diaphragm; however, the chest and abdominal x-rays do reveal a radio-opaque shadow in the central lower chest/epigastrium region (Figure 1).

Figure 1.

Electrocardiography shows a sinus rhythm with no evidence of ischemic changes. The patient is instructed to take nothing orally and is placed on intravenous fluids. His symptoms are persistent, and a repeat chest and abdominal x-ray at 12 hours postadmission shows that the previously seen shadow has not changed position. The decision to intervene endoscopically is made.

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