Clinical Case (Part 1)

There is a principle in writing known as "Show; don't tell." I offer this case as an example of that principle, though the context probably won't be clear until after the discussion in Part 2, in which the answer will be given.

A very active 67-year-old woman came to me several times complaining of mid-right-sided back pain that occasionally radiated around her right side to her abdomen. This had been going on for about one month before she first consulted me. She played a lot of tennis (right-handed) and was under the impression that she had pulled something, although she didn't recall any specific trauma. The pain seemed to be exacerbated by certain motions, though she was unable to be more specific about what kinds of movements. Sometimes it had a "boring" quality. It sometimes woke her at night. Occasionally when it came around to her abdomen it had the quality of "hunger pains" though there seemed to be no relation between the pain and eating (ie, neither exacerbated nor relieved by food, nor consistently recurring before or after eating.) OTC pain relievers taken intermittently provided inconsistent relief.

Other than that she felt fine. The pain didn't radiate anywhere else. There was no nausea, vomiting, anorexia, weight loss, black/tarry stools, melena or bright red rectal bleeding. There were no urinary symptoms. Past history was unrevealing. Her blood pressure was a little elevated, but we were just starting to keep an eye on it. She had never smoked and consumed very little caffeine or alcohol.

Physical exam was basically normal. She had full range of motion of her spine. Perhaps there was some tenderness in the right lower thoracic region, but while in the office she would usually say, "It's not hurting right now." There was no costovertebral angle tenderness. Her abdomen revealed normally active bowel sounds, and was soft. There were no masses or organomegaly, and there was no tenderness or guarding anywhere. There were no skin rashes or lesions. Lab tests were all within normal limits including urinalysis, liver function tests and hemoglobin/hematocrit.

My initial impression (shared by the patient) was musculoskeletal back pain, so she was treated conservatively with heat, massage and OTC acetaminophen. She returned several times, giving a story of increasing pain unresponsive to treatment. She felt very strongly that something was wrong with her back, so when I suggested it was time for some imaging studies, she readily agreed to spinal x-rays. I tried to explain to her my concern that an intra-abdominal process might be causing her pain, so she reluctantly agreed to an ultrasound (although she only went for the x-rays.)

Finally, she called one evening telling me that the pain was now "excruciating," so I sent her to the ER where the diagnosis was made.

Post your thoughts in the Comments.
(Hint/disclaimer: listen to the hoofbeats. No zebras here.)