Pulmonary embolism: An abdominal pain masquerader
A 48-year-old male presented to the emergency department with a 1-year history of intermittent right upper quadrant abdominal pain. He had been seen by his primary care physician 1 week earlier for the same pain and had an ultrasound performed. The patient stated he was unaware of the results and that today the pain became acutely worse. The patient denied any other associated symptoms. He denied any personal history or family history of medical problems. The patient was a smoker, drank up to a six-pack of beer daily, and used marijuana. He did not take any medications.\nThe vital signs were as follows: Blood pressure 112/52, pulse 82, respiratory rate 16, oxygen saturation 99% on room air. He was afebrile. Physical exam revealed a well appearing male in moderate distress secondary to pain. His abdominal examination was remarkable for severe right upper quadrant pain to palpation without guarding or rebound. There was no costovertebral angle tenderness. His lung sounds were clear bilaterally. The patient remarked that the abdominal pain was made worse with deep inspiration. His cardiac exam was normal.\nLaboratory analysis revealed a normal complete blood count, complete metabolic profile, urinalysis, and lipase. A right upper quadrant ultrasound examination was performed, which demonstrated a positive sonographic Murphy's sign and slight dilation of the common bile duct at 0.66 cm [Figure and ]. A chest radiograph was significant for a right lower lobe infiltrate in the lung periphery []. At this time, it was felt that this could represent a Hampton's hump; however, the patient had a low pre-test probability for having a PE. A d-dimer test was added and was positive (1.0 mg/mL fibrinogen equivalent units, normal <0.05) at which point a computed tomography angiogram (CTA) of the chest was performed. On CT a large central PE was identified in the right main pulmonary artery [Figure and ]. The right lower lung lobe contained a peripheral based wedge-shaped opacity consistent with pulmonary infarct []. Anticoagulation was started in the emergency department and the patient was admitted. A formal echo done during the patient's admission showed a small atrial septal defect with left to right shunting that did not require closure. No other etiology for thromboembolism was identified.