Question

A 39-year-old woman is brought to the emergency room by her fiancé for severe abdominal pain for the past 5 hours. She was watching TV after dinner when she felt a sudden, sharp, 10/10 pain at the epigastric region that did not go away. Ibuprofen also did not help. She reports recurrent abdominal pain that would self-resolve in the past but states that ""this one is way worse."" Her past medical history is significant for diabetes and an appendectomy 2 years ago. The patient endorses nausea and 1 episode of emesis, but denies fevers, chills, chest pain, shortness of breath, diarrhea, constipation, urinary symptoms, paresthesia, or weakness. She used to smoke marijuana in college and drinks about 2 beers a week. A physical examination demonstrates an overweight woman in acute distress with diffuse abdominal tenderness. Her vitals are within normal limits. Laboratory values are shown below:

Hemoglobin: 12 g/dL
Hematocrit: 34%
Leukocyte count: 4,900/mm^3 with normal differential
Platelet count: 160,000/mm^3

Serum:
Na+: 138 mEq/L
Cl-: 98 mEq/L
K+: 4.8 mEq/L
HCO3-: 25 mEq/L
Glucose: 123 mg/dL
Ca2+: 6.9 mg/dL
AST: 387 U/L
ALT: 297 U/L
ALP: 168 U/L
Lipase: 650 U/L (Normal 0 - 160 U/L)

What is the best next step in the workup of this patient?

a. Abdominal computed tomography with IV contrast
b. Abdominal computed tomography without IV contrast
c. Abdominal magnetic resonance imaging
d. Abdominal ultrasound
e. Upright chest and abdominal radiograph

Answer 1

An abdominal ultrasound is the recommended next step to evaluate the patient's severe abdominal pain and elevated lipase, which suggest the possibility of acute pancreatitis or another hepatobiliary condition.

Step-by-step explanation:

The best next step in the workup of this patient with severe epigastric pain and elevated lipase levels is abdominal ultrasound. This diagnostic procedure is non-invasive and effective in identifying gallstones and evidence of inflammation in the pancreas, which could suggest acute pancreatitis or other hepatobiliary disease. Given this patient's history of diabetes, which is a risk factor, along with her elevated lipase levels, it is important to examine the structure and condition of the pancreas and gallbladder.

The patient's severe abdominal pain and history of diabetes and an appendectomy suggest the possibility of a more serious condition requiring further evaluation. The CT scan with IV contrast can provide detailed images of the abdomen and help identify any potential causes of the patient's symptoms, such as appendicitis, pancreatitis, or another abdominal pathology. The IV contrast can enhance the visualization of the organs and blood vessels, allowing for a more accurate diagnosis.