Intended for healthcare professionals

Student Education

Picture quiz: End of the bed

BMJ 2004; 328 doi: (Published 01 June 2004) Cite this as: BMJ 2004;328:0406235
  1. Stephen Goldie, fifth year medical student1,
  2. Stephen Bicknell, consultant physician1
  1. 1University of Glasgow
  2. 2Gartnavel General Hospital, Glasgow


During a clinical placement on a medical ward, the specialist registrar challenges you to make “an end of the bed diagnosis.” The patient is a 49 year old man, a former smoker, who presented with severe dyspnoea and pitting oedema in the lower limbs. He has a history of recurrent deep venous thrombosis and pulmonary embolism. From the end of the bed you can see the patient is wearing a face mask providing high flow oxygen, his jugular venous pressure is markedly raised, and the appearance of his abdomen is grossly abnormal (figure below).


  1. Describe the gross abnormality seen on the patient's abdomen.

  2. What diagnosis can be made from the end of the bed?

  3. What is the most likely cause of this condition?


  1. The patient's abdomen is abnormal because of several grossly dilated tortuous veins. One especially prominent vessel runs through the centre of the epigastrium.

  2. Given the extent of the abnormality and the pattern of distribution of the vessels, the patient has a serious obstruction of the inferior vena cava.

  3. The most likely cause of obstruction of …

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