A 47-Year-Old Man With Acute Epigastric Pain

Erik D. Schraga, MD

Disclosures

June 30, 2015

Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case you would like to suggest for a future Case Challenge, please contact us.

Background

A 47-year-old man presents to the emergency department (ED) with a chief complaint of waking up with severe abdominal pain. He states that over the past week, he has had intermittent, gaslike epigastric pain and a sensation "like I need to burp"; as of this morning, the pain has acutely worsened. It is now radiating in a bandlike pattern throughout the patient's upper abdomen and to his back. The pain is most intense when he lays flat on his back and seems to be slightly better when he is sitting upright.

The patient has mild nausea but has not vomited. He has not experienced any chills or fever, and he denies having any diarrhea (although he did have one nonbloody bowel movement before coming to the ED). He reports no chest pain, shortness of breath, or palpitations. He drinks approximately six to eight beers daily but has no chronic medical conditions and does not take any medications.

He denies using over-the-counter pain medications, including nonsteroidal anti-inflammatory drugs (NSAIDs). He does not have any medication allergies.

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