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

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


June 01, 2016

Physical Examination and Workup

The patient appears uncomfortable on physical examination. Her vital signs are remarkable for a rapid heart rate of 112 beats/min and a low blood pressure of 96/48 mm Hg. Her other vital signs include a temperature of 96.4°F, a respiratory rate of 18 breaths/min, and an oxygen saturation of 98% while breathing room air. Minimal soft-tissue swelling of the right forehead is noted, with a small ecchymosis. The heart sounds are rapid but without murmurs. The lungs are clear to auscultation.

The abdomen is diffusely tender to palpation, which is greatest in the right upper quadrant, where there is positive guarding and rebound tenderness. Palpation of the lower quadrants results in increased right upper-quadrant pain. No distention or ascites are appreciated. No hepatomegaly, palpable pulsatile masses, or bruits are appreciated. The radial and dorsalis pedis pulses are equal bilaterally.

Figure 1.

Intravenous access is obtained, and the patient is given 1 L of normal saline, which leads to improvement in her heart rate and blood pressure. Multiple doses of intravenous hydromorphone are given, with temporary relief of her pain but no improvement in tenderness.

An upright chest radiograph and three-view abdominal radiographs are unremarkable, with no visible free air or bowel abnormalities. Laboratory tests reveal a borderline low hemoglobin level of 11.5 g/dL and a normal white blood cell count of 6.8 x 103 cells/µL. Aminotransferase, bilirubin, and lipase levels are all normal.

CT of the abdomen and pelvis with intravenous contrast is performed (Figure 1).


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