Arnie is a generally fit and healthy 30-year-old engineer who comes to the office roughly twice a year. When I see him, we often speak about squash, a sport he loves to play.
Recently, Arnie came to see me because he had epigastric pain that lasted for 4 days. There was no associated nausea, vomiting, bowel change or fever. On examination, I noted minimal epigastric tenderness, but the exam was otherwise normal. He preferred over-the-counter ranitidine to the prescription of a proton pump inhibitor and I told him to call if his symptoms didn't improve.
When he came back 6 weeks later, he had a 5-day history of epigastric discomfort. It was worse than before and he'd been to the emergency department the previous night. They gave him some antacid and omeprazole at 20 mg/day, which he hadn't started yet. He was in the office now because he wanted my opinion. His previous bout had stopped while he was on the ranitidine.
Arnie's pain mildly worsened with respiration. There were no associated urologic, pulmonary or cardiac symptoms. He didn't smoke and consumed alcohol only infrequently. His past medical history included herniorrhaphy, a fractured ankle and deep vein thrombosis (DVT) while in the cast, environmental allergies and a prolonged bout of pneumonia a couple of years earlier.
He was afebrile on exam, and there were no significant findings except very mild epigastric tenderness. He was ambulatory and not acutely ill clinically. I told him to take the omeprazole 40 mg daily and ordered routine bloodwork. I also said that if he didn't improve we'd likely be arranging scope for him.
Arnie returned later that afternoon with much worse pain in the upper abdomen. There was some nausea and also more tenderness. Knowing Arnie wasn't usually a complainer, I sent him back to the hospital for more urgent testing. What do you think they found?
Arnie's bloodwork revealed a white blood cell count of 9.2 x 109/L, hemoglobin of 155 g/L and platelets at 242 x 109/L -- all in the normal range. His chemistry wasn't very helpful either, as his electrolytes were normal, creatinine was at 98 µmol/L, amylase at 72 U/L, aspartate aminotransferase at 26 U/L and alanine aminotransferase at 68 U/L. Not my first guess as a differential diagnosis, his ultrasound showed dilatation of the splenic and portal veins with thrombosis. He was anticoagulated and recovered. A gastroscopy was entirely normal.
A review of his family history revealed that his sister had suffered 2 DVTs. Further testing also showed that this man had an underlying protein C and S abnormality, which explains his tendency to coagulate. I strongly suspect that the pneumonia that had lingered a couple of years earlier was in fact a small pulmonary embolus. He's now on long-term warfarin and continues to play squash -- with my repeated warnings to be careful.
We'll send you $100 if we print your diagnostic challenge. Send case description (app. 450 words) with final diagnosis and outcome to: firstname.lastname@example.org.