Marcus Chan is a 19-year-old college student who comes to the Student Health clinic after 2 days of vomiting and abdominal pain.
He has been participating in his university’s Spring Rush for fraternity membership and three days ago drank alcohol at a rush party until he blacked out. He says his friends took him home, observed him vomiting several times, and gave him Tylenol and Gatorade before he passed out.
He awoke the next morning “feeling hungover” and with nausea, vomiting, and belly pain that have not improved with time as his hangover improved. He is vomiting even when he tries to drink water or juice and can’t hold down food at all for the last 2 days. He came in because he is worried he has an ulcer from drinking because he is feeling too dizzy and weak to walk to the dining hall and because the pain is too bad to let him sleep, even with Tylenol and Motrin.
Exam: T 99.1 HR 100 sitting 125 standing BP 100/50 sitting 90/45 standing SpO2 99% on room air. Weight 260 lbs., BMI 35
Gen: pale, tired appearing, obese
HEENT: flat neck veins, mucous membranes dry
Chest: tachycardic, lungs clear, exam limited due to habitus
Abdomen: tender to palpation and percussion, no bowel sounds after listening for 60 seconds.
Rectal/GU: testes in normal position and nontender, no hernias, rectal exam with brown stool, guiac negative
Extremities: cool, no edema
Hgb 16.4 g/dL
Sodium 149 mEq/L
Potassium 3.9 mEq/L
Bicarbonate 18 mmol/L
BUN 40 mg/dL
Creatinine 2.1 mg/dL
Glucose 81 mg/dL
Calcium 9.3 mg/dL
AST 120 units/L
ALT 50 units/L
Bilirubin 3.5 mg/dL
Serum amylase: 200 u/dL
Serum lipase: 600 u/dL
PT/INR: 18 sec/2.0
PTT: 36 sec
Sp Grav: 1.030
Leukocyte esterase negative
Shows normal common bile duct diameter and gallbladder of normal size with visible sediment Ultrasonic Murphy’s sign is negative.