100 Cases in Clinical Medicine

CASE 77: ABDOMINAL PAIN

History

A 70-year-old woman has been complaining of upper abdominal pain which has increased
over the last 3 days. It has been a general ache in the upper abdomen and there have been
some more severe waves of pain. She has vomited three times in the last 24 h. On two or
three occasions in the past 5 years she has had a more severe pain in the right upper
abdomen. This has sometimes been associated with feeling as if she had a fever and she was
treated with antibiotics on one occasion. Her appetite is generally good but she has been off
her food over the last week. She has not lost any weight. There have been no urinary or
bowel problems but she does say that her urine may have been darker than usual for a few
days and she thinks the problem may be a urinary infection.

In her previous medical history she has had hypothyroidism and is on replacement thy-
roxine. She has annual blood tests to check on the dose; the last test was 3 months ago.
She has had some episodes of chest pain on exercise once or twice a week for 6 months
and has been given atenolol 50 mg daily and a glyceryl trinitrate spray to use sublingually
as needed.

Examination

Her sclerae are yellow. Her pulse is 56/min and regular. Her blood pressure is 122/80 mmHg.
There are no abnormalities in the cardiovascular system or respiratory system. She is tender
in the right upper abdomen and there is marked pain when feeling for the liver during inspir-
ation. No masses are palpable in the abdomen. She is clinically euthyroid.

Normal

Sodium 139 mmol/L 135–145 mmol/L

Potassium 4.1 mmol/L 3.5–5.0 mmol/L

Urea 6.4 mmol/L 2.5–6.7 mmol/L

Creatinine 110 &mol/L 70–120&mol/L

Calcium 2.44 mmol/L 2.12–2.65 mmol/L

Phosphate 1.19 mmol/L 0.8–1.45 mmol/L

Total bilirubin 83 mmol/L 3–17 mmol/L

Alkaline phosphatase 840 IU/L 30–300 IU/L

Alanine aminotransferase 57 IU/L 5–35 IU/L

Gamma-glutamyl transpeptidase 434 IU/L 11–51 IU/L

Thyroid-stimulating hormone 2.3 mU/L 0.3–6.0 mU/L

INVESTIGATIONS

Questions

• How do you interpret these findings?


• What is the appropriate management?