Elizabeth Katz

CUNY York PA – S

Chief complaint: Emesis and abdominal pain x 1 day

HPI

25 yo female with 10 pack-year hx, PMH of drug and alcohol abuse and dependence and pancreatitis presents to the ED with a chief complaint of emesis. She reports many episodes of NBNB emesis with nausea, severe epigastric pain and tremulousness. She states that symptoms began suddenly while she was in the street, the pain is a 9/10 and does not radiate.  She reports drinking one gallon of vodka two days ago but denies any drug or alcohol use since. This has occurred previously on two occasions, one in 2018 and one in 2015. With the 2015 episode requiring hospital admission. She denies any fever, chills, recent weight loss or gain, change in bowel habits, dysuria or known pregnancy.

DDx: pancreatitis, alcohol withdrawal, acute intoxication, gastritis

PMH

Alcoholic pancreatitis (2015)

Drug and alcohol abuse and dependence (2010)

PSH

None

Medications

None

Allergies

No known allergies

FH

Mother: HTN, alive and well

Father: unknown

Sister: alive and well

SH

She is unmarried and is sexually active with multiple partners and admits inconsistent contraception use. She reports heavy alcohol use, and admits smoking 1.5-2 PPD, heroin and cocaine use. She denies recent travel and states that to her knowledge her vaccines are up-to-date.

ROS

• Constitutional: malaise and fatigue x 1 day
• GI: admits N/V epigastric pain, anorexia, and denies history of heart burn, jaundice, change in bowel habits, rectal bleeding
• Neurological: admits to tremors

PE

• VS: BP 123/72 left arm, sitting position; pulse 102 regular; O₂sat 100% room air; respirations 20/min; temp 98.2°F oral; weight 65.8 kg; BMI 24.2
• Patient is alert and oriented x 3, appears stated age and is moderately uncomfortable and diaphoretic
• HEENT: normocephalic atraumatic, PERRLA, EOMI, face symmetric, mouth and throat unremarkable
• Neck: FROM, trachea midline, no palpable cervical adenopathy
• Heart: tachcardic, RR, no heaves, gallops, murmurs
• Lungs: equal breath sounds b/l, no wheezing/rales, no retractions or accessory muscle use
• Abdomen: very tender over epigastrum, intentional guarding, no CVA tenderness
• Extremities: no deformities or injuries, distal pulses intact
• Skin: diaphoretic, skin warm, no rashes or visible lesions
• Neuro: age appropriate neuro exam, no focal abnormal findings

Labs

• Glucose 64
• ALT 224
• AST 1115
• Alk Phos 201
• Lipase 781
• WBC 2.20

Assessment: 25 yo F with PMH as stated above, presenting with chief complaint of emesis and abdominal pain, has hx of pancreatitis, likely a recurrent episode now with possible component of alcohol withdrawal.

Plan

• NPO
• Order labs (UA, CMP, lipase, magnesium, CBC, INR, HCG quantitative)
• Obtain IV access and administer fluids
• POC glucose
• POC urine pregnancy
• 12 lead ECG

Ongoing care: Patient has alcoholic pancreatitis, to be admitted for pancreatitis with epigastric pain and elevated lipase greater than 3x upper limit of normal.

Refined DDx: alcoholic pancreatitis, alcohol withdrawal, hepatitis C secondary to IV drug use

Patient education and f/u:

• Alcohol dependence and abuse counselling
• Smoking cessation counseling
• Drug dependence and abuse counseling, including referral to methadone clinic, discussion of safe injection practices
• Safe sex practices, referral to Gyn to receive routine care – pap smear