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.
Abdomen appears distended. Midline scar from previous surgery visible.
Abdomen feels hard, very tender in all areas
No bowel sounds audible on auscultation
Faeces on glove. No blood noted.
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:
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