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:
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)
General examination:Abdominal examination:
Mr A is in significant pain – he appears restless, sweating and is complaining of severe stomach cramping.
Abdomen appears distended. Midline scar from previous surgery visible.On palpitation:
Abdomen feels hard, very tender in all areasRectal examination:
No bowel sounds audible on auscultation
Faeces on glove. No blood noted.Side Room Investigations
Heart rate: 108
Respiratory rate: 19
Urine dipsticks: clear
The GP decides to do an abdominal X-ray. This is the resulting image:
Based on the clinical information and the special investigations, what is your diagnosis?
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.
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Image: Abdominal X-ray showing pathology from By James Heilman, MD (Own work) [CC BY-SA 3.0 or GFDL], via Wikimedia Commons