Epigastric pain

Abstract

Dr. Richard Phillips:Today's case is that of a 27-yearold woman with a history of bipolar disorder who presented to the Emergency Department (ED) complaining of a 3-week history of epigastric and right upper quadrant (RUQ) pain. She described the pain as sharp and constant with intermittent exacerbations that radiated to the back. There was no change in the quality of the pain with food intake. There was no recent history of trauma. The review of systems was notable for nausea, emesis, dark stools for a few days, lightheadedness for one week, and a fever of 38.3°C 2 days before presentation.Three weeks before presentation, the patient was seen in the ED complaining of multiple episodes of hematemesis. At that time it was believed that her symptoms were secondary to gastritis; she was started on antacids, which resolved her symptoms. The symptoms returned 4 days before presentation, at which time she saw her primary care physician, who reaffirmed the diagnosis of gastritis and sent her home with proton pump inhibitors.Dr. Eric Nadel: Are there any questions about the initial presentation?Dr. William Krauss: I would like to know more about her medical history, social history and medications before we proceed.Dr. Phillips: The patient's past medical history was notable only for bipolar disorder diagnosed 8 years ago for which she had been admitted to an inpatient psychiatric facility twice in the last 6 weeks before this presentation. The patient had no prior surgeries. The only medications included olanzapine 20 mg taken at night and valproic acid 1000 mg, also taken at night. The patient lived alone and was unemployed at the time. She denied alcohol and drug use but did admit to smoking in excess of two packs of cigarettes per day for the last 12 years. The family history was non-contributory; she was adopted and had not been in contact with her biological parents.In the ED, the patient's vital signs were: temperature 36.7°C, blood pressure (supine) 122 mm Hg/76 mm Hg, heart rate (supine) 80 beats per minute, blood pressure (sitting) 110 mm Hg/77 mm Hg and heart rate (sitting) 92 beats per minute, respirations 20 breaths per minute. The patient was in no acute distress. Mucous membranes were moist and clear of lesions. Cardiac examination demonstrated an audible S1 and S2 in regular rate and rhythm without evidence of any murmurs, rubs or gallops. The lungs were clear to auscultation bilaterally. The abdomen was soft with RUQ tenderness but no evidence of rebound or guarding. Rectal examination revealed no tenderness and the stool was negative for occult blood. The cranial nerves II-XII were intact and she was alert and oriented to person, place and time. The lower extremities were warm and well perfused without evidence of peripheral edema.Dr. Nadel: Are there any questions about the initial assessment and thoughts as to ED management?Dr. Danny Pallin: The differential diagnosis in this case is extensive and includes cholecystitis, cholelithiaCase Presentations of the Harvard Emergency Medicine Residency are coor...