Left Upper Quadrant Pain and Pyrexia in a 50-Year-Old Man

Anusuya Mokashi, MD; Dhana Rekha Selvaraj, MD, MBBS; Chandrasekar Palaniswamy, MD; Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR; Klaus L. Irion, MD, PhD

Disclosures

December 09, 2016

Physical Examination and Workup

Physical examination reveals a physically fit white male in no acute distress. His weight is 180 lb and his height is 5'10". His oral temperature is 102.3°F (39.1°C). His blood pressure is 130/80 mm Hg, his pulse is regular at 85 beats/min, and his heart sounds are normal, with no murmurs, rubs, or gallops. The patient's respirations are 14 breaths/min and unlabored. His lungs are clear on auscultation.

Examination of the head and neck is unremarkable. Abdominal examination reveals tenderness in the left upper quadrant, accompanied by slight muscle guarding; no rebound or rigidity is noted, and no discrete masses are palpated. Mild edema of the soft tissues in the left upper quadrant is observed. Costovertebral tenderness is absent. Bowel sounds are normal and no organomegaly is found. Rectal examination reveals no masses, and the fecal occult blood test is negative.

Figure 1.

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The laboratory analysis includes a complete blood cell count (CBC) with differential, a complete metabolic panel, a coagulation profile, a lipase test, and a urine analysis. The CBC reveals an elevated white blood cell (WBC) count, with a left shift. The rest of the laboratory results are within normal limits: creatinine is 1.2 mg/dL (106.1 µmol/L), glucose is 90 mg/dL (4.9 mmol/L), prothrombin time is 12.1 seconds, partial thromboplastin time is 28.5 seconds, and lipase is 85 units/L. The urine analysis is negative for bacteria and has a specific gravity of 1.010, with 1.2 WBCs per high-powered field, 0.9 red blood cells per high-powered field, and no casts. It is noted in the record that the patient had a negative HIV test approximately 4 months earlier, and had a screen for sickle cell disease that was also negative.

A CT scan is performed (see Figures 1–4).

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