Question

case: A 42-year-old Hispanic woman presents to the emergency department (ED) complaining of 24 hours of severe, steady epigastric abdominal pain, radiating to her back, with several episodes of nausea and vomiting. She has experienced similar painful episodes in the past, usually in the evening following heavy meals, but the episodes always resolved spontaneously within an hour or two. This time the pain did not improve, so she sought medical attention. She has no medical history and takes no medications. She is married, has three children, and does not drink alcohol or smoke cigarettes. On examination, she is afebrile, tachycardic with a heart rate of 104 bpm, blood pressure of 115/74 mm Hg, and shallow respirations of 22 bpm. She is moving uncomfortably on the stretcher, her skin is warm and diaphoretic, and she has scleral icterus. Her abdomen is soft, mildly distended with marked right upper quadrant and epigastric tenderness to palpation, hypoactive bowel sounds, and no masses or organomegaly appreciated. Her stool is negative for occult blood. Laboratory studies are significant for a total bilirubin (9.2 g/dL) with a direct fraction of 4.8 g/dL, alkaline phosphatase 285 IU/L, aspa

Answer 1

accompanied by nausea and vomiting. She has a history of similar episodes, which usually resolve spontaneously, but this time the pain has not improved. She is afebrile but tachycardic and has scleral icterus. On examination, her abdomen is soft, mildly distended, and she has marked right upper quadrant and epigastric tenderness. Laboratory studies show elevated total bilirubin, direct bilirubin, and alkaline phosphatase levels.

Based on the provided information, this patient's clinical presentation is concerning for acute pancreatitis. Acute pancreatitis typically presents with severe abdominal pain, often radiating to the back, and is associated with nausea and vomiting. Other common symptoms include fever and tachycardia. The physical examination may reveal abdominal tenderness and signs of systemic illness, such as icterus in this case.

The elevated bilirubin levels and alkaline phosphatase suggest an obstructive component, possibly due to gallstones obstructing the common bile duct (choledocholithiasis). This can lead to biliary pancreatitis.

Further evaluation with imaging studies, such as abdominal ultrasound or computed tomography (CT) scan, may be needed to confirm the diagnosis and assess the extent of pancreatitis. Management may involve supportive care, pain control, addressing the underlying cause (e.g., gallstone removal), and monitoring for complications.

This patient's clinical presentation warrants prompt evaluation and management in the emergency department, given the severity of symptoms and potential complications associated with acute pancreatitis.

Step-by-step explanation: