Case presentation

A 22-year-old woman was admitted to the medicine service with generalised abdominal pain and nausea. Medical history included a recent motor vehicle accident resulting in multiple orthopaedic injuries and development of a chronic pain syndrome. The patient denied other pertinent medical, social or family history. Medications included escitalopram, cyclobenzaprine, and oxycodone 10 mg every 6 hours as needed for pain.

The patient’s initial vitals were temperature 37.3°C, heart rate 81 beats/min, respiratory rate 16 breaths/min, and blood pressure 89/59 mm Hg. Pertinent physical exam included diffuse tenderness to palpation of the abdomen without peritoneal signs and no skin hyperpigmentation. Laboratory evaluation revealed a normal complete blood count, basic metabolic panel, liver function, urinalysis, and lipase. A CT scan of the abdomen and pelvis …