A patient with right upper quadrant abdominal pain, hypotension and dyspnoea.

Abstract

A 67-yr-old female was transferred to the National Taiwan University Hospital, Tapai, Taiwan on 2 May 2001 after several days of abdominal pain, dyspnoea and hypotension. She initially complained of an intermittent cramping pain over the right upper quadrant (RUQ) of her abdomen 4 days prior to admission. Sudden onset of dyspnoea and altered mental status were noticed 2 days later. She was then sent to the emergency room of a local hospital where a body temperature of 37.5°C and blood pressure reading of 80/30 mmHg were noted. Abdominal sonography showed multiple gallstones and swelling of the gallbladder wall with the “triple-layer” sign. Her haemodynamics were stabilised by fluid challenge and empirical antibiotic therapy. She was then transferred to the National Taiwan University Hospital for further treatment. The patient was hypertensive for several years while under regular medical control. She had also received hormone replacement therapy for treatment of osteoporosis (1 tablet·day−1 of an unknown drug for 2 yrs). Her medical history was otherwise unexceptional. On examination, she was drowsy. Her body temperature was 37.5°C, blood pressure 160/92 mmHg, pulse rate 120 beats·min−1 and respiratory rate 24 breaths·min−1. The sclerae were not icteric. The pupils were isocoric with prompt light reflex. The neck was supple, without jugular vein distension or lymphadenopathy. The chest expanded symmetrically and breathing sounds were clear. No heart murmurs were detected. There was tenderness and muscle guarding at the RUQ abdomen with equivocal Murphy's sign. The liver and spleen were not palpable. The bowel sounds were hypoactive. No lower leg oedema was noticed. Neither skin rash nor petechiae were found. The initial laboratory studies revealed: a white blood cell count of 16.61×109 cells·L−1, with 86.2% neutrophil, 5.6% monocytes and 8.1% lymphocytes; a red blood cell count of 4.19×1012 cells·L−1; …