CASE
A 74-year-old male came to the emergency department at 4 am complaining of right upper quadrant (RUQ) abdominal pain and right-sided shoulder pain that started 2 hours before arrival and awoke him from sleep. The patient denied nausea, vomiting, diarrhea, dyspnea, dysuria, fever, chills, chest pain, or palpitations.
History The patient had a history of rheumatoid arthritis (RA), psoriasis, and hypertension. His medications included verapamil (Verelan) and naproxen. He denied any history of smoking and reported only social alcohol use. The remaining review of systems was unremarkable.
Physical examination Vital signs were temperature, 98.2°F; heart rate, regular at 80 beats per minute; respiration rate, 16 breaths per minute; BP, 186/84 mm Hg. The abdomen was soft, nondistended, and mildly tender in the RUQ, with a positive Murphy sign and rebound. An ECG indicated a sinus rhythm with a heart rate of 76 beats per minute. The corrected Q-T interval (QTc) was 470 milliseconds. No acute ST-T wave changes or ventricular ectopy were detected. Significant laboratory results included a WBC count of 10.9 × 103/µL, neutrophils, 81.2%; hemoglobin 11.7 g/dL; hematocrit 34.7%. Results of a complete metabolic profile were normal. The first set of cardiac enzyme determinations was within normal limits. A bedside ultrasound was ordered. IV fluid, famotidine (Pepcid) 20 mg by IV push, and a GI cocktail resulted in initial improvement. However, when the patient reported worsening pain, abdominal radiographs were ordered (Figure 1).
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