Wednesday, March 30, 2011

Intern Report Case Presentation 3.6

Case Presentation by Dr. John Wilburn

Pt. E.R. is a 25 Y.O Hispanic female presenting to the emergency Department with a 4 day history of stomach pain in the periumbilical and epigastric area radiating around the right side to the back.  Patient describes the pain as Constant 8/10 sharp cramping that is aggravated with food and water. Alleviated by sitting up, patient did take Tylenol but it did not help her pain. She reports nausea and has had four episodes of non bloody emesis the night before after eating some bread, the emesis was described as “yellow with food in it”. She denies any change in the color or consistency of her bowel movements. LMP was 2 week ago and was a normal cycle. Her abdominal pain has been worsening over the past 4 days and it woke her up from her sleep at 4 am, at which time she decided to seek medical attention.  She denies any trauma or ever having pain like this before. Denies any recent travel and reports that her kids at have had a cold but no GI illnesses. The patient feeling feverish denies any chest pain, shortness of breath or rashes.

ROS:  Negative except as noted per HPI

Past medical history: Denies Diabetes or asthma
Past surgical history: C-section x2
Allergies: Penicillin (rash)
Medication: None
Family history: Father has HTN and Diabetes
Social History: Denies Tobacco, Drinks alcohol socially, denies any illicit drug use. She is currently employed as a waitress and lives at home with her two children ages 3 and 1.

Physical Exam:
VS: 37.5 pulse 106 Bp 128/86 RR 16  99% Room air
General: Laying on her side holding her epigastric area appears uncomfortable but in NAD
HEENT: NC/AT Perrl sclera mildly icteric. EOMI No nasal Discharge no pharyngeal erythema Mucous membranes are dry sublingual has a yellowish color to it.
Neck: Supple No tenderness Trachea is midline. No thyromegaly or Lymphadenopathy
Respiratory: CTAB no W/R/R
Cardiovascular: Tachycardia regular rythm, S1S2 no M/R/G good pulses
Chest: No visible rashes/scars/ no reproducible chest wall tenderness
Abdomen: No lesions or rashes on inspection, Obese, +BS, ST/Tender to Palpation in Epigastric area and RUQ +Murphys sign, No Rebound tenderness, - Rovsings – rigidity. No Guarding.
Extremities: Strength 5/5 b/l upper and Lower ext. Full AROM and PROM palpable radial and dp pulses, SILT and symmetric.
GU: Wnl on inspection no erythema or discharge – No CMT or Adnexal tenderness. Slide shows epithelial cells
Rectal: No Hemorrhoids good tone, no palpable masses. Guaic Negative 

Laboratory Results:
Electrolytes: Na 140, K 3.9, Cl 104, HCO3 24, BUN/Cr 14/0.8, Glucose 125, Ca 8.8
CBC:  Wbc 10.9, H/H 12.3/39.2, Platelets 427
ALT 193, AST 159, Alk Phos 288, Tbili 2.8, Dbili 1.3, Lipase 8005, Amylase 800
Urine hCG: Negative
U/A: 3+bili, 3+ ketones, Sp Gravity 1.025, trace blood, trace LE, Nitrite negative, rbc 2-5
Wbc 5-10, epithelial cells 5-10, trace bacteria 

Ultrasound Demonstrates

  1. Although there is no gold standard for this diagnosis which of the following is considered by most experts to be the most sensitive and specific test available?
    1. CRP
    2. Lipase
    3. Trypsin
    4. Amylase
    5. ALT 
       2.  Which of the of the following Liver Enzymes is the single best marker for biliary     etiology of this diagnosis

a.     ALT
b.     LDH
c.     Total Bilirubin
d.     AST
e.     Alkaline Phosphatase 

  3. Which of the following complications of this diagnosis has the highest mortality?
a.     Acute Renal Failure
b.     Myocardial Infarction
c.     Infected Pancreatic Pseudocyst
d.     ARDS
e.     Splenic Vein Thrombosis

4. Which of the following is the definitive treatment?

a.     Cholecystectomy
b.     ERCP
c.     Lexipafant
d.     ERCP with sphincterotomy and stone extraction
e.     Conservative management

Please submit your answers as a comment. Your submission will not immediately post.  Answers with a case discussion will post on Friday.  If you have any difficulty, please contact the site administrator at Thank you for participating in Receiving’s: Intern Report

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