Image: Clubbing and hypoxia

Abstract

A 40-year-old male with no significant past medical history presented to the emergency department with a severe headache for 3 days. On physical examination, the patient appeared very uncomfortable and was hypoxic on room air to 86%. He was ambulatory with no apparent focal neurologic deficits, but his fingers were clubbed. Electrocardiogram showed normal sinus rhythm. Computed tomography (CT) angiogram of the chest incidentally revealed a portosystemic shunt in the left upper quadrant. CT brain and magnetic resonance imaging (MRI) brain with and without contrast were obtained (Figures 1 and 2).