This is our 3rd case in a case series exploring the care of patients with GI related illnesses in the Emergency Department. Similar to our "Out on a Limb" and "Sepsis Smackdown" case series, the case presented is followed by a series of questions, with a discussion in the comment section facilitated by the post authors. In approximately 1 month, the authors of the post will conduct a combined simulation/small group session reinforcing the learning points from the posts during Grand Rounds. Around this time, they will also curate the comments from the discussion and publish a post highlighting these learning points. Looking forward to a great discussion!
It's been a busy Monday night shift. 2 hours in and it seems like all you've seen is belly pain after belly pain. You hesitate and think maybe it's just a figment of your imagination but a quick look at the track board tells you nope, 5 patient's with abdominal pain in your 10 bed pod and a new patient arriving to C40 with, of course, abdominal pain. You meet the squad and get report.
James is a 42 year old gentleman who says that he has been vomiting for the past day. He looks uncomfortable, complains of non focal pain throughout his abdomen, and vomits non-bloody non-bilious emesis once after presentation. His vital signs are all within normal limits and you order up some labs and give him fluids and anti-emetics. He has had no dietary changes, no sick contacts, and no history of abdominal surgeries. On exam he has a soft abdomen with predominately epigastric abdominal tenderness to palpation with voluntary guarding but no rebound tenderness.
His vitals and labs are notable for the following:
HR 108, BP 137/82, RR 14 O2 99% on RA.Temp: 99.8
- CBC: WBC 15.4, hemoglobin 14.5, platelets 240
- BMP: Na 132, K 4.8, BUN 22, Cr. 1.2
- Hepatic: T Bili 1.2, ALT 87, AST 67, Alk Phos 105, Albumin 3.7
- Lipase: 1230
When responding you need only respond to 1 or 2 questions (leave some fodder for others!) and please begin your response with Q1, Q2, etc, denoting to which question you are responding.