Sudden LUQ Pain
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History of Present Illness:
A 52-year-old male presents to the ED for sudden LUQ abdominal pain. He denies vomiting, diarrhea or other complaints.
Vital Signs & Physical Exam:
Vital signs are normal except for a pulse of 111. Physical exam is otherwise normal except for epigastric tenderness without guarding
Initial Differential Diagnosis:
- Gastritis
- MI
- Pancreatitis
- Gallstones
- Syphilis, the great imitator
Initial Diagnostic Testing:
- EKG: normal
- Labs: normal including lactic acid
- Imaging: CT shown below (this one is subtle)
QUESTIONS:
- What does the case image show?
- What should you do next?
- Want a 1-minute consult/tutorial on this case?
- Want to know what happened with this patient?
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ANSWERS:
- What does the case image show? The image shows a SMA dissection. It is not easy to see and was actually missed by the first radiologist. A coronal view is shown below with a white line as an indicator
- What should you do next? Consult vascular surgery. They recommended 24 hour observation then discharge home on Xarelto
- Want a 1-minute consult/tutorial on this case? See yellow area from sample page below.
- Want to know what happened with this patient? See case conclusion below tutorial page.
1-Minute EM Consult on the topic for this case from the Emergency Medicine 1-minute Consult Pocketbook
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CASE CONCLUSION: Patient was admitted, seen by vascular surgery and started on aspirin & Xarelto. He remained stable and was discharged after 24 hours.
CASE LESSONS:
- Always remember there are sometimes Zebras, especially when the clinical presentation doesn’t fit more common conditions. The sudden onset of pain was a clue here, as was the unexpected CT finding:)
- Never underestimate the importance of luck, but also that luck favors those who work hard.