Unfolding the Diagnosis

A CLINICAL PROBLEM-SOLVING article by Gadi Lalazar from Hadassah–Hebrew University Medical Center, Jerusalem.
A previously healthy, 25-year-old man was admitted to the hospital because of abdominal pain, nausea, vomiting, and weight loss. Two weeks before his admission, fever (40°C), chills, and weakness developed. To control his fever, the patient ingested ibuprofen at a dose of 400 mg four times a day for more than a week. Subsequently, abdominal discomfort and nausea developed, and he presented to the emergency department owing to worsening of epigastric pain and vomiting. The physical examination was consistent with dehydration. The temperature was 36°C. The spleen and liver were mildly enlarged. Laboratory tests revealed an elevated white-cell count, elevated liver enzyme levels and albumin level of 1.4 g per deciliter (normal range, 3.5 to 5.0). Viral serologic testing was positive for IgM antibodies to cytomegalovirus.
This patient presented with a clinical picture of viral infection and severe epigastric pain. Because he had ingested high doses of NSAIDs, NSAID-induced gastritis was initially suspected as the cause of his abdominal pain. However, the finding of severe hypoalbuminemia was not easily explained by either viral infection or his NSAID use. The identification of this abnormality led to reconsideration of the working diagnosis and a shift from a “probability approach” to a “causal reasoning” approach.

【発音】

• 'Hebrew ヒーぶるー
• Je'rusalem じぇルーせれむ
• ibu'profen あいびゅープロウふぇん