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 –Â 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 Â MCV 100.5 Â Normal differential, normal RBC morphology
James Hassel
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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