A 23-year-old man, a resident of Istanbul, Turkey, is visiting relatives in Chicago when he presents to a local hospital with the acute onset of severe abdominal pain, pain on the right side of his chest during deep inspiration, and fever.

He describes 3 to 4 recurrent episodes of similar discomfort earlier in life, all of which resulted in hospitalizations. On one such occasion, he had an “abdominal operation” which failed to uncover the cause of his symptoms.  The earlier episodes of pain and fever used to resolve within 36 to 48 hours with bed rest and pain medication.

Recently, he was placed on a medication that he took on a daily basis, which resulted in no recurrences for 2 years until this current trip to the United States when he forgot to bring the medication along with him.

He denies illicit drug use, does not smoke, but he enjoys 1-2 cans of beer per day. He was adopted at age two, and there is no knowledge of family history.

Physical examination reveals an acutely uncomfortable young man complaining of abdominal and chest pain.

Vitals:

• Temperature: 101⁰ F
• Blood Pressure: 110/60 mmHg
• Pulse: 120 beats/minute and regular
• Respirations: 24/minute and shallow
• Oxygen sensor reads 96%

Examination of the chest reveals a friction rub over the right lower lobe without rales or signs of consolidation. The abdomen is distended, rigid and rebound tenderness is present. Bowel sounds are hypoactive. The remainder of the physical examination is normal including a rectal examination.

Laboratory studies:

• Complete blood count - normal
• Electrolytes - normal
• Blood urea nitrogen - 23 mg/dL
• Creatinine - 1.2 mg/dL
• Alanine amino transferase - 34 U/L
• Amylase - 130 U/L
• Chest x-ray - small right pleural effusion
• Abdominal CT - air filled bowel; no free air

Answer Options:

Acute pancreatitis; observation, pain control and rectal aspirin, as needed, for fever

Perforated viscus into the retroperitoneal space; exploratory laparotomy

A ruptured bag of heroin in the intestines; laparotomy

Familial Mediterranean Fever; Colchicine 0.6mg every 2hrs until pain relief is achieved (maximum adult dose of 3 mg/day)

Except for Hospitalists, Emergency Medicine physicians, and Interventional Cardiologists, most physicians will spend the bulk of their professional time with patients in an office setting.

Here is where finely tuned clinical skills are most important in leading to accurate diagnoses, fewer complications resulting from unnecessary tests and procedures, and lower costs. These Bedside Diagnostic Challenges reinforces the value of these clinical skills and tests users on their knowledge of them.

Bedside Diagnostic Challenge questions are issued periodically every month as a free benefit of Med-Challenger.

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Paul Griner MD, MACP graduated from the University of Rochester School of Medicine and completed his residency at the Massachusetts General Hospital, Boston, MA. He has served the University of Rochester School of Medicine as Chief Resident in Medicine and as Professor, Department of Medicine. He has served as a Senior Lecturer at Harvard Medical School and consultant at the Massachusetts General Hospital where he introduced a mentoring program for the faculty of General Internal Medicine. Dr. Griner is board certified in internal medicine.