Given these changes from the original case, what is your diagnosis?
What is your diagnostic explanation?
As compared to the long case, this patient is a 35 year old female with abdominal pain for 2 days. She states the pain is in the upper part of the abdomen and goes right through to her back. It feels like a terrible aching pain. She has not had similar symptoms like this in the past. Eating seems to make it worse, but it is the same at night as it is in the day. She tried TUMS but they didn’t help. The pain is so severe the patient is unable to eat. The patient denies fever, but states she is nauseated and has vomited many times in the last day. She denies diarrhea or constipation. No blood in stool, no dark stool. No skin color changes. LMP 2 weeks ago. No vaginal discharge. No chest pain, dyspnea, or cough. No recent trauma. No known gallstones. She drinks alcohol every day after work, about 4-5 glasses of wine. Has been a heavy drinker since junior high, and when younger used to get intoxicated to the point of passing out. The patient states that she has had a similar sensation in her upper abdomen once or twice before but it didn’t last long and it wasn’t this bad. Never diagnosed with ulcers. No steroid use. No smoking. No recent hospitalization. Only medication is estrogen-based oral contraceptives. Family history is negative except for colon cancer in father in his 70s.
Vital Signs: BP 110/70, P 120, R 18, T 37.8 C, O2 98% on RA
General: The patient is alert and oriented x3. Appears to be in pain.
Skin: Normal. No rash. (No stigmata of liver disease. No jaundice. No bruising. No Cullen’s or Grey-Turner sign).
HEENT: PERRLA. EOMI. Normal. (No icterus, No pallor). Oral mucosa is dry.
Cardiovascular: RRR. No murmur. Equal pulses and perfusion throughout. No sign of DVT. No edema.
Abdominal: Very Tender to superficial palpation in the epigastric region with guarding. Tender to deep palpation in the LUQ. No RUQ, RLQ, LLQ, or suprapubic tenderness. No rebound. No bruising or skin changes, no caput medusa, liver edge is normal, negative Murphy sign. No splenic enlargement. Normal bowel sounds.
Rectal: Brown stool. Hemoccult negative.
Genitourinary: Normal external genitalia. No vaginal discharge. No cervical discharge, no cervical motion tenderness, no mass.
Back: No spinal tenderness, no muscular tenderness, no CVA tenderness.
Extremities: No edema, no sign of DVT.
Labs: Lipase – elevated, Amylase – elevated, Urine Pregnancy Test – Negative, *WBCs – elevated, *Liver Enzymes – Normal