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Correspondence to Dr Timothy Pinder, [email protected]
Background
This case reinforces the holistic examination of patients and putting them in context to solve atypical scenarios.
Case presentation
A man in his late 50s presented to the emergency department with a 2-day history of progressively worsening abdominal pain, episodes of vomiting and lower back pain. He had suffered similar intermittent episodes over the last 2 weeks. His comorbidities included medication-controlled essential hypertension, an ex-smoker and an ischaemic stroke which had caused expressive dysphasia 6 weeks prior to admission.
His medications included: indapamide 2.5 mg once daily, clopidogrel 75 mg once daily, solpadol 30/500 mg four times per day, amlodipine 10 mg once daily and bisoprolol 2.5 mg once daily.
On physical examination, he had tenderness in the right upper abdomen and right flank pain with no palpable masses or an aneurysm. He was apyrexial and his observations were stable. He was found to have an ejection systolic murmur; its cause not clearly known then. The diagnosis was uncertain and his initial differential diagnosis included: renal tract calculi, peptic ulcer pathology, cholecystitis and pancreatitis.
His blood tests showed a haemoglobin of 111 g/dL, white cell count of 15.7x109/L, platelet count of 476x109/L, neutrophils 13.4x 109/L and a potassium of 2.4mmol/L. His liver function tests and amylase were normal. An arterial blood gas was normal. Plain chest and abdominal X-ray films were normal. An ECG demonstrated sinus rhythm.
He was subsequently admitted to the medical ward for further observation and investigations. At this point, a first episode of fever was noted which subsequently lasted 4 days. In the ward, his abdominal pain resolved very slowly but spontaneously and a general surgical review concluded that clinically he did not have an acute abdomen.
Investigations
During his admission for this symptomatology, a CT of the kidneys, ureters and bladder was performed as renal tract calculi was clinically suspected (figure 1). No calculus pathology was seen but a 17 mm aneurysm in the superior mesenteric artery (SMA) was found which was then thought to be an incidental finding. A vascular surgical team review was recommended which concluded: no further investigation acutely but further surveillance imaging would be needed.
The medical team further assessed him with a...