EDUARDO BENCHIMOL SAAD
A 34 year old white man was admited to emergency room at 4:00 am complaining of severe abdominal pain, nausea and vomiting.
He said that all started about 2 hours before arriving at the ED, when he suddenly wakened with some periumbilical discomfort and intense nausea, which made him vomit 3 times. The vomit had a bilious character with some food residues but no blood. After about 30 minutes, the pain intensified, now including the entire abdomen, but mainly in the epigastrium, irradiating to the back and testicles. It had a dull pattern. He innitialy atributted his symptoms to a huge amount of shrimp that he had for dinner earlier that evening and took acetaminophen, which was not helpfull.
He was a previously assymptomatic man and worked as a director of a trading company in Rio de Janeiro, Brazil. He denied fever, diarrea, colickly pain, hematuria, icterus, dispnea, dispeptic symptoms, contact with animals, recent travel, alchool use, smoking, drug abuse, trauma, and took no medications except for some vitamin pills. He has never received a blood transfusion and had no epidemiologic risk factors for HIV infection.
His past medical history is unrevealing except for an episode of acute pericarditis 10 years before. There was no important diseases in his family, and he had a brother that died 2 years before after infectious complications following chest trauma in a car accident.
In examination, we found a very anxious and distressed patient, which couldn't stand laying down in bed, changing position very often and walking around as he was looking for a more comfortable position. He was oriented, and the skin and mucous membranes appeared normal. The pulse was 110, respirations 20, and blood pressure was 100x60. Head and neck examination was unrevealing. The heart was normal and the lungs were clear. Abdominal examination was diffusely painfull, mainly in the epigastrium, with some peritoneal irritation. The patient wouldn't let us palpate it throughly, but no visceral enlargment was found. Bowel sound were slighty diminished. Legs and arms were normal, without clubbing, cyanosis or edema. A resumed neurological examination didn't show any abnormalities.
Afeter innitial evaluation in the ER ( which included complete blood count, electrolytes, biochemistry and radiological evaluations ), the patient was admited to the Intensive Care Unit, where he was adequately monitored and a Pulmonary Artery Catheter was inserted.