A 76 year old woman with severe ischaemic heart disease being treated with aspirin, clopidogrel and metoprolol presents with severe abdominal and back pain, 6 hours after being discharged home from a routine cardiac angiogram via the femoral route. List the differential diagnosis. Outline how you would investigate the cause of the abdominal pain.
The differential diagnosis could be large and should include pancreatitis, retroperitoneal
haematoma, aortic dissection, cholecystitis, infarcted gut, Gastro-Intestinal perforation, diverticular disease, pericarditis, myocardial infarction/ischaemia, pneumothorax, etc.
Investigation includes, in addition to a proper history (character, type, severity, position of pain, associated features etc), and a full clinical examination (signs of all the above possibilities) a number of relevant investigations. Consider: Amylase, Haemoglobin (has it fallen?), white blood cells, Urea &Electrolytes, lactate, Liver Function Tests, Chest X-Ray, ECG and troponin, ultrasound abdomen, echocardiogram, CT scan abdomen depending on the most likely cause. A good answer would also include what would be expected from the investigations ordered.
This question closely resembles Question 2 from the first paper of 2004.
In short, a thorough history and detailed physical examination would be a good start.
- Aortic dissection
- Retroperitoneal hematoma
- Ischaemic gut
- perforated viscus
- splenic infarct
One would assess the abdomen particularly, looking for masses.
One would auscultate the abdomen, listening for a bruit of aortic dissection
One would also look for features of shock, metabolic acidosis, and peritonism, suggestive of ischaemic gut (due to emboli dislodged from the aorta)
A CXR, ABG, ECG, a full panel of bloods including FBC, LFT, amylase/lipase and inflammatory makers.
An abdominal ultrasound looking for vascular tree damage, and a CT of the abdomen with IV contrast to image the intraabdominal organs and their supplying vessel