57 year old female with a history of cholecystectomy and hysterectomy presents with 2 days of chest pain and vomiting. Yesterday the patient began to have epigastric pain that radiated to the midline chest. Pain onset was at rest, constant, and not worsened with exertion. She has had non-bloody emesis every 30 minutes since pain onset. She is a non-smoker, no other cardiac risk factors. She had a normal stress test in 2013 with a normal EF. Father died of a MI at the age of 63.
Positive for subjective fever, rhinorrhea, chest pain, vomiting and abdominal pain. Otherwise other pertinent ROS negative.
VS: BP 176/100, HR 97, RR 16, SpO2 96%, T98.5.
No acute distress. Neck supple. Regular rhythm, tachycardic, no murmur. Normal breath sounds. Symmetric distal pulses. Abdomen is soft, tender to RUQ and epigastric area, no guarding or rebound tenderness. Rectal exam normal, hemoccult negative. Skin warm, dry. No focal neuro deficits.
- Perforated Viscous
- Mesenteric Ischemia
Patient given ASA, NTG for chest pain. She received IV zofran for nausea, IV fentanyl for pain. SL NTG dropped SBP from 140 to 90, NTG subsequently withheld. A bedside US showed a normal sized abdominal aorta. EKG showed NSR, no acute ischemia, normal axis, no change from previous EKG two years prior.
Labs: WBC 20, Hgb 14.6. POC troponin 0.07 (mildly elevated). AST 642, ALT 550, Alk Phos 136, t bili 2.3.
Lipase 6464 - leading to the diagnosis of pancreatitis.
The patient's pain was controlled and was being prepared for admission. Then, something went wrong....
The patient then became pale, tachycardic in the 140s, and has a syncopal episode in the ED. A second large bore IV was placed and additional IV crystalloid fluids administered. A repeat EKG shows no acute changes. The patient wakes up after IVF bolus and is feeling better, HR improves and BP stabilizes.
A bedside US FAST exam is positive for fluid in the abdomen. CT angio of the chest and abdomen showed a dissecting left hepatic artery pseudoaneurysm with hemorrhagic extension to the perihepatic, perisplenic and intraperitoneal left abdominal areas. Repeat Hgb now 7.0 (previously 14.6), lactate 7.4. The patient received stat PRBC infusion and general surgery was consulted. Interventional radiology was consulted as well and the patient underwent embolization of the hepatic artery.
The patient did well after the procedure and was discharged 1.5 weeks later, eventually diagnosed with Polyarteritis Nodosa.
Submitted by Dr. Josh Timpe, PGY-2