Case Four

HPI:

Patient is a 41 year old white male who presents complaining of 2 weeks of abdominal pain and distention. The pain is diffuse, dull and has gradually become more epigastric in location for the previous 1-2 days. It has been of varying intensity, but never completely relieved. The patient's pain continued to worsen and became sharp, primarily in the epigastrium. He vomited once on the day of his ED evaluation. He was seen by his PMD 9 days ago for these symptoms and was prescribed dicyclomine as well as an emema which gave him mild relief. An abdominal ultrasound was performed 3 days ago for continued symptoms and revealed some gallbladder sludge, mild diffuse ascites and a 1cm right renal cyst. There were no gallstones and the biliary ducts appeared intact. The pancreas was normal. The patient developed loose stools subsequently. Stool for ova and parasites was performed on 3 specimens and was normal. The patient reports having a similar episode 3 years ago.

ROS:

Has had generalized weakness for 2 weeks, early satiety. No fever, weight loss, hematemesis, melena, pruritis, chest pain, dyspnea, cough, dysuria. No travel in the last 3 years. Has a cat.

Medications: Zantac, dicyclomine.

Allergies: None known.

PMHx: No diabetes, HTN, heart disease, pulmonary disease, renal disease, or liver disease.

Past Surgical Hx: Varicocelectomy, circimscision.

Social Hx: No tobacco, drinks an occassional glass of wine. Denies drugs. Works as a chemist.

Family Hx: Remarkable only for HTN in father.

Physical Exam:

Vitals: T=36.9, P=92, R=16, BP=140/100

General: Alert and oriented to person, place and time. In no acute distress. Well developed.

Skin: No rash. Non-icteric.

HEENT: PERLLA, EOMI, conjunctiva pink, mucous membranes moist. Throat clear.

Neck: Supple, no JVD, no lymphadenopathy.

Lungs: Clear bilaterally. Equal breath sounds.

Heart: Regular rate, rhthym. No rubs or murmurs or gallops.

Abdomen: Mildly distended. No spider angiomata or caput

medusae. Bowel sounds slightly increased. Soft, nontender.

No hepatosplenomegally. Moderate shifting dullness and fluid wave.

Extremities: No edema, cyanosis or deformities.

Genitalia: normal male. Normal testicles, nontender.

Rectal: Normal tone. Normal prostate. Heme negative brown stool.

Neurologic: Within normal limits.


Laboratory tests:

CBC: wbc=15.3; 53% eosinophils, 33% polys, 8% lymphs.

hgb=16.7, plts= 365

Na=140, K=4.0, Cl=100, CO2=23, BUN=7, Cr=0.9, glu=95,

T.Bili=1.5.

Transaminases were all wnl. Alk phos was wnl. lipase= 108(wnl).

Urinalysis was unremarkable.

Abdominal xrays: Nonspecific gas pattern. Three small, nondifferential air -fluid levels in small bowel without

distention. No free air. Air seen in the rectum.

What is the diagnosis?