Question

A 72-year-old man presents to the ED complaining of worsening abdominal pain over the last few hours. He also reports nausea, but denies fever, vomiting, or changes in the appearance of his bowel movements. His medical history is significant for type 2 diabetes mellitus, hypertension, coronary artery disease, stroke, atrial fibrillation, and peptic ulcer disease. Due to his recurrent bleeding peptic ulcers, he does not take warfarin. His surgical history is significant for an appendectomy as a child. His medications include metformin, lisinopril, metoprolol, and omeprazole. He has a 50-pack-year history of smoking. His temperature is 37.6 C (99.7 F), blood pressure is 146/80 mm Hg, pulse is 115/min, and respiratory rate is 20/min. On physical exam, he is in acute distress due to the pain. Pulmonary auscultation reveals scattered wheezes and decreased air entry. His heart rate is irregularly irregular, with no murmurs, rubs or gallops. Abdominal exam is significant for decreased bowel sounds and diffuse tenderness. Initial laboratory evaluation is as follows:

Na 138 mEq/L, Cl 101 mEq/L, HCO3 12 mEq/L, BUN 21 mg/dL, Cr 0.9 mg/dL, glucose 190 mg/dL, amylase 240 U/L (normal < 65 U/L).
What is the most likely diagnosis in this patient?

a. Peptic ulcer perforation
b. Acute cholecystitis
c. Acute mesenteric ischemia
d. Diabetic ketoacidosis
e. Acute pancreatitis

Answer 1

The most likely diagnosis for the patient's symptoms and lab results, including the elevated amylase level, is acute pancreatitis. Option E is correct.

Step-by-step explanation:

The most likely diagnosis for the 72-year-old man with a history of peptic ulcer disease, diabetes, hypertension, coronary artery disease, stroke, atrial fibrillation, and a significant smoking history, presenting with worsening abdominal pain, nausea, and an elevated amylase level, is acute pancreatitis.

This condition is suggested by his notably elevated amylase, which is specific to pancreatic injury or inflammation. The presence of nausea without vomiting or fever and diffuse abdominal tenderness can also be consistent with this diagnosis.

The other conditions listed, such as peptic ulcer perforation, acute cholecystitis, acute mesenteric ischemia, and diabetic ketoacidosis, are less likely because the clinical and laboratory findings are more fitting with acute pancreatitis.

The most likely diagnosis in this patient is Acute pancreatitis . Acute pancreatitis is characterized by severe abdominal pain, nausea, and vomiting. It is often associated with high levels of pancreatic enzymes, such as amylase and lipase. In this patient, the elevated amylase level is consistent with acute pancreatitis.