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Epigastric Pain, Otherwise Healthy


Epigastric pain x3 days in an otherwise healthy middle-aged man prompts an in-office abdominal ultrasound. What do you see?

A 56-year-old man comes to your office for his yearly executive physical. He mentions that he has had 3 days of epigastric pain with occasional radiation to his mid-back. He denies any vomiting, diarrhea, dark stool, fever, trouble breathing, or other complaints. He tried an antacid with no relief. His past medical history is notable for hypertension and diabetes. He is a smoker but does not abuse drugs.

On physical examination, his vital signs are normal. His lungs are clear and his heart is regular without murmur. He has slight epigastric tenderness but no guarding or mass. There is no rash. Extremities are normal. You have your office phlebotomist draw blood for his yearly lab studies and your tech does an ECG, which is normal. You use your office ultrasound to image his gallbladder and aorta and obtain the following images.

1.    What does the image below show?
2.    What should be your next step in management?

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