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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:

  1. What does the case image show?  
  2. What should you do next?  
  3. Want a 1-minute consult/tutorial on this case? 
  4. Want to know what happened with this patient?

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ANSWERS:

  1. 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
  2. What should you do next?  Consult vascular surgery.  They recommended 24 hour observation then discharge home on Xarelto
  3. Want a 1-minute consult/tutorial on this case?  See yellow area from sample page below.
  4. 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

CLICK HERE TO LEAR MORE ABOUT THIS BOOK

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:

  1. 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:)
  2. Never underestimate the importance of luck, but also that luck favors those who work hard.
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