If your NCAA bracket is already busted, here is your first chance this spring to win yet another COtM. Take a look at the situation below:

 

A 38 year-old man with a history of EtOH abuse presents with epigastric pain x 3 days. Pain began 3 days ago after drinking 10 beers, was intermittently exacerbated by foods/drinks, and then spontaneously resolved. Pain recurred again last night after drinking 2 beers and has been slowly worsening since then, now at its maximum. Pain is located in the epigastric area, is non-radiating and now constant. The patient reports several episodes this morning of non-bilious, blood-tinged emesis. He also reports “feeling shaky” and reports a history of EtOH withdrawal in the past. Denies chest pain, dyspnea, fever/chills, melena, diarrhea, blood in the stool, dysphagia, sick contacts, or recent travel.

 

Meds: denies

Allergies: NKDA

Social: denies drugs/cigarettes

 

ROS: Negative aside from what is mentioned above

 

PE:
VS – 97.9, 97, 18, 99%, 102/66
GEN – alert, uncomfortable due to pain

HEENT – Dry mucous membranes, sclera non-icteric

CV – S1S2, RRR, no m/r/g
LUNGS – CTAB, no w/r/r
ABD: +epigastric/RUQ/LUQ tenderness w/ voluntary guarding, no rebound/rigidity, +mild distension

NEURO: no focal deficits

EXT: No c/c/e

 

Labs:

CBC 6.47>9.8/29.7<82  MCV 100.5  Normal differential, normal RBC morphology

Coags PT 13.4, INR 1.3, PTT 25.5
Comp 141/3.9/98/20/5/0.84<15  Tprot 7.2 Alb 3.5 AST 140 ALT 37 Alk phos 121 Tbili 1.4
Ca 9.1, Mg 1.7, Phos 3.7
pH 7.32 lactate 5.2
CXR: reveals no abnormalities
Prior CT abdomen/pelivs 2013: multiple nodularities within the liver
While you were reviewing the above lab values, the nurse comes and tells you that the patient just lost consciousness while lying in his stretcher.
Confusing? Surely, and there are many possible diagnoses. So keep your differentials wide and post answers to the following questions:
1. What is you differential diagnosis for this patient?
2. What is your workup?
3. What would your current management entail?
If you give the best answer you will be declared the winner in about one week’s time.  Happy sleuthing!
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James Hassel

4th Year EM-IM Resident at SUNY Downstate/Kings County Hospital

Latest posts by James Hassel (see all)


James Hassel

4th Year EM-IM Resident at SUNY Downstate/Kings County Hospital

1 Comment

edenkim · March 21, 2016 at 2:24 am

labs show he has anemia and thrombocytopenia likely 2/2 chronic ETOH abuse and normal rbc morphology so i’m assuming no schistocytes = no ttp, mildly elevated INR, AST elevation, low Mg all consistent with chronic ETOH abuse. labs also significant for elevated anion gap of 23, elevated lactate, and acidosis on shock. delta-delta >2 suggests metabolic acidosis + alkalosis, which fits with his history of vomiting

ddx: alcoholic ketoacidosis, pancreatitis, PUD vs. alcoholic gastritis, mallory-weiss tear, toxic alcohol ingestion, ETOH withdrawal, cholelithiasis, less likely infectious etiology like cholecystitis or ascending cholangitis, unlikely cardiac ischemia, unlikely malignancy but could be insulinoma.

workup:
-send ETOH level and ketones, serum osmol, type and screen, lipase
-stat FSG and EKG
-consider adding trops on
-bedside RUQ sono and FAST exam
-CT abd/pelvis once stable

Management:
-NPO
-D50 stat since his glucose on the comp was 15
-thiamine, folate, mag repletion
-begin fluid resuscitation with D5NS with frequent fingersticks and if no longer hypoglycemic, switch to NS.
-zantac and PPI.
-repeat a shock in about an hour or two and if potassium is below 3.5 i’ll add a KCl to the fluids, hopefully lactate clears
-if high serum osmol gap, id ask specifically about toxic alcohol ingestions, and consider starting fomepizole
-monitor closely for signs of ETOH withdrawal, librium on regular schedule and ativan PRN if clinically indicated
-intubation if patient starts to have bloody emesis to protect airway

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