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Updated 03 July 2015

What's your diagnosis? - Case 14: abdominal pain and swelling

Mr A presents to his GP, complaining of severe abdominal pain. In this week’s case, we give you a case history and insight into his special investigations. See if you can figure out what’s ailing Mr A.

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Mr A, a 45 year old attorney, is suffering from severe abdominal pain. Two years ago he had similar pain, which turned out to be a peptic ulcer that perforated the stomach lining. He underwent emergency surgery to repair the ulcer, and never had any recurring symptoms. 

The following is a summary of the GP’s notes:

History

Presents with one-day history of cramp-like abdominal pain.
Not confined to a specific area on the abdomen.

Progressively worsening “swelling” of the abdomen

Nausea and vomiting for past 6 hours

Unable to pass any stool or wind (flatus)

Previous peptic ulcer disease. Taking omeprazole daily.

Previous surgery: perforated peptic ulcer repair (2 years ago)

On Examination

General examination:
Mr A is in significant pain – he appears restless, sweating and is complaining of severe stomach cramping.

Abdominal examination:

Abdomen appears distended. Midline scar from previous surgery visible.

On palpitation:

Abdomen feels hard, very tender in all areas
No bowel sounds audible on auscultation

Rectal examination:

Faeces on glove.  No blood noted.

Side Room Investigations


Heart rate: 108
Respiratory rate: 19
Urine dipsticks: clear

Special investigation

The GP decides to do an abdominal X-ray. This is the resulting image:

abdominal x-ray showing pathology

Based on the clinical information and the special investigations, what is your diagnosis?

Clues:

1.  The history and the examination should provide you with enough information to make a provisional diagnosis.
2.  On the X-ray, look for repetitive patterns to support your diagnosis made from the history.

What’s your diagnosis? Join the guesswork on our Facebook page, or comment below. 

NOTE: Health24's on-site GP Dr Owen Wiese will reveal new cases on Thursdays. We'll post the answer with the story on Mondays, or you can get it via the Daily Tip – sign up here.

Previously on What's Your Diagnosis

What's your diagnosis? -  Case 1: vomiting and weight loss
What's your diagnosis? -  Case 2: eye pain
What's your diagnosis? -  Case 3: strange behaviour and a bullet in the back
What's your diagnosis? -  Case 4: seeing odd things
What's your diagnosis? - Case 5: mysterious lungs
What's your diagnosis? - Case 6: runner with seizures
What's your diagnosis? - Case 7: swollen knee
What's your diagnosis? - Case 8: bloody semen
What's your diagnosis? - Case 9: confusing neurological signs
What's your diagnosis? - Case 10: diabetic teenager with unusual signs and symptoms
What's your diagnosis? - Case 11: bruising with no apparent reason
What's your diagnosis? - Case 12: severe tummy pain
What's your diagnosis? - Case 13: severe sore throat

Image: Abdominal X-ray showing pathology from By James Heilman, MD (Own work) [CC BY-SA 3.0 or GFDL], via Wikimedia Commons

 
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