CASE
A 71-year-old female presented to our family medicine clinic with complaints of nausea and abdominal cramping. She said she had been in good health until the previous day at 2:15 pm, when she developed severe bilateral pain in her lower back. The patient said the pain, which radiated to her abdomen, felt like muscular pain caused by poor posture. A few minutes after the pain started, she said, she broke out in a cold sweat, went to the bathroom, vomited, and had a normal bowel movement. The pain lasted 2 more hours and then became a persistent cramping. She reported difficulty sleeping until she took 600 mg of ibuprofen at 2:30 am and was able to fall asleep.
History The patient's history was significant for Hodgkin lymphoma (now in remission), venous thromboembolism (which occurred during treatment for the lymphoma, with subsequent anticoagulation), hypertension, dyslipidemia, hypothyroidism, and total hysterectomy. She denied any history of gallbladder disease, abdominal aneurysm, or kidney stones. Her current medications included pravastatin (Pravachol) 40 mg daily; levothyroxine 100 mcg daily; hydrochlorothiazide 25 mg daily; calcium 1,000 mg daily; fish oil 1,000 mg twice daily; and valsartan (Diovan) 80 mg daily. The patient reported no drug allergies.
Physical examination At presentation, her back pain had resolved but
her nausea and abdominal cramping
persisted. She reported chills but denied any fever. Examination results were largely unremarkable, except that cardiac auscultation demonstrated an irregular rate and rhythm without murmurs, rubs, or gallops.
The patient's ECG is shown in Figure 1. Urinalysis in the clinic revealed 1+ leukocytes, 2+ protein, nonhemolyzed trace of blood, and trace ketones. The remaining findings were normal.
Two days previously, routine laboratory tests had shown the following values: chloride at 97 mmol/L (101-114); alkaline phosphotase, 125 IU/L (32-91); otherwise normal chemistry panel; normal CBC; total cholesterol, 235 mg/dL (0-200); triglycerides, 118 mg/dL (0-150); HDL cholesterol, 56.7 mg/dL (40-60); LDL cholesterol, 156 mg/dL (0-100); and thyroid-stimulating hormone, 4.390 mIU/L (0.340-5.60).
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