Acute abdominal pain, painful left shoulder and near collapse.

A 28-year-old patient presented to the emergency department with acute pain in the left upper abdominal quadrant and left shoulder, and a near collapse. He had an unremarkable medical history, used no medication and had not experienced any recent trauma. During the previous two weeks he had been ill with flu-like symptoms. Physical examination showed blood pressure 120/65 mmHg, heart rate 85/minute, temperature 36.2 °C, supraclavicular lymphadenopathy and pain in the left upper abdominal quadrant without signs of peritonitis. Examination of the left shoulder was normal. Laboratory results showed a haemoglobin level of 8.8 mmol/l, leukocytosis 12.1 x 10/l, lymphocytosis 7.13 x 10/l and elevated liver screen (aspartate aminotransferase 231 U/l, alanine PHO TO QU I Z