In each issue, JUCM will challenge your diagnostic acumen with a glimpse of x-rays, electrocardiograms, and photographs of dermatologic conditions that real urgent care patients have presented with.

If you would like to submit a case for consideration, please e-mail the relevant materials and presenting information to editor@jucm.com.

The patient is a 52-year-old tourist who presents with a four-day day history of abdominal pain, constipation, not passing gas, and nausea. The patient was not comfortable but was hemodynamically stable. Temperature was normal, pulse was 94, BP was 195/99. The abdomen was markedly distended. WBC was 11. View the x-ray taken (Figure 1 and Figure 2) and consider what your diagnosis and next steps would be. Resolution of the case is described below.

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The Resolution

Review of the x-ray reveals a great deal of gas and fluid in the large bowel down until the sigmoid. There is no distension of the small bowel. There is no air, nor contents in the rectum. At first glance, one might suspect obstruction at the level of the sigmoid.

The patient was referred to hospital and, initially, a diagnosis of sigmoid volvulus was made. However, CT revealed the symptoms were actually the result of incarcerated inguinal hernia.

Acknowledgment: Scott Fields, MD, was the radiologist on this case, which was presented by Nahum Kovalski, BSc, MDCM.