Introduction

An 87-year-old woman was admitted with a 2-month history of worsening shortness of breath. She had a non-productive cough and denied any history of chest pain. She had a history of pulmonary tuberculosis, diverticular disease, and a ventral suspension. Respiratory function testing identified severe airways obstruction and she was commenced on inhaled bronchodilators to good effect. Arterial blood gas examination on air revealed pH 7.44, pCO₂ 6.7 and pO₂ 9.0. Full blood count, urea and electrolytes, and liver function tests were all normal. Two days after admission she complained of left pleuritic chest pain although with no increase in breathlessness. Repeat arterial blood gas examination showed pH 7.38, pCO₂ 5.9 and pO₂ 7.7. A diagnosis of possible pulmonary embolism was made and she was anticoagulated with intravenous heparin. The following morning she complained of severe left lower abdominal pain and nausea. Photographs of her abdomen are shown in figure 1. On examination she . . . [Full text of this article]