A 61-Year-Old Woman With Abdominal Pain and Syncope

James J. McCombie, MB ChB; Erik D. Schraga, MD

Disclosures

June 01, 2016

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 61-year-old woman presents to the emergency department after rapid onset of severe upper abdominal pain while watching TV and eating dinner. The pain was constant and radiating to the right shoulder.

The patient used effervescent antacid/analgesic tablets and, subsequently, a glycerin suppository; however, despite having a normal bowel movement, she did not have any relief. She also used hydrocodone and diazepam that she had at home for back spasms, but she continued to experience worsening pain. She felt nauseous and, when bending over to the toilet to vomit, she became lightheaded, had a syncopal episode, and hit her head on the bathtub. She has not had any bloody or dark stools.

Currently, any attempt at movement causes severe abdominal pain. The patient continues to have nausea but has not had any vomiting. She feels slightly lightheaded. She denies having any chest pain or palpitations. She has not had any fever.

The patient's medical history is significant for hepatitis C, for which she received treatment with interferon alpha 3 years ago. She also has a history of anxiety, chronic lower back pain, and hypertension. Her surgical history includes an appendectomy that was performed 15 years ago and endometrial ablation.

The patient's medications include lisinopril, diazepam, and hydrocodone. She was previously a heavy drinker but has not used alcohol in over 5 years.

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