Digestive case study

[cmonkey]

I haven't looked up all the labs, but this just SCREAMS cholecystitis.

Also, is it wrong to be happy to find someone with cholesterol higher than mine? I've read that statins can increase the incidence of stones, and she's presenting with the same symptoms my dad had before he had his lap chole.

A 66-year-old woman is taken to the hospital by her son after she complained of abdominal pain, sweating, and just not feeling good. Her son has just come to visit he thinks her color looks bad. He thinks she looks jaundiced. She is rather embarrassed, explaining to the nurse that it is just indigestion and gas from the double order of onion rings she ate. She knows the rings are not good for her. She gets gas, indigestion, and diarrhea every time she eats them, but they are SOOOO good. She tells the nurse the only medication she is on is a cholesterol-lowering drug. While taking the history, the woman begins to complain of shoulder pain, becomes nauseated and vomits.

Her lab results are as follows: serum albumin: 4.9g/dl

total serum cholesterol : 400 mg/dl

serum amylase 80 IU/L

serum insulin 15 μU/ml

RBC's : 4.0 X 106/ mm3

WBC's : 12,000/mm3

total serum bilirubin : 2.1 mg/dl

urine bilirubin : 0.4 mg/dl

[Daytonite, BSN, RN]

the shoulder pain, sweating, nausea and vomiting and elevated cholesterol bothers me. they are signs of a heart attack. heartburn and a feeling of gas or complaint of indigestion is often confused for a gi problem when a heart attack is actually going on. wbcs could be elevated because of inflammatory response because there has been damage to the heart muscle. for a 66-year old, the er staff will probably rule out a heart attack first.

serum albumin: 4.9g/dl (normal)

total serum cholesterol

: 400 mg/dl (elevated--normal is less than 200mg/dl)

serum amylase 80 iu/l (normal)

serum insulin 15 μu/ml (normal)

rbc's : 4.0 x 106/ mm3 (slight low--normal female 4.7-6.1)

wbc's : 12,000/mm3

: (slight high--normal 5,000-10,000/mm3)

total serum bilirubin

: 2.1 mg/dl (elevated--normal 0.1-1 mg/dl)

urine bilirubin : 0.4 mg/dl

i had gallbladder attacks before i finally had my cholecystectomy and i was doubled over with pain that felt like a knife stabbing me through my liver straight though to my back. the pain was so bad i could hardly breathe because each breath in made the pain worse. the pain is caused by muscle spasm along the cystic duct as these stones try to pass.

[cmonkey]

Can't be MI, though, because we're studying the digestive system. Aha!

I would agree otherwise, though. I'm actually kind of glad that we're doing this by system or I'd NEVER come up with a dx for these cases. Too many are too much like too many things.

[cmonkey]

Oh, and the pain! I seriously thought I was having a gb attack last night on the way home. Turns out I ate too many dried cherries earlier in the day. Did you know that gas pain can make you want to die just so you'll feel better? It can.

NB: ease up on the dried fruit, people.

[Daytonite, BSN, RN]

i went looking in my medical differential diagnosis textbook. about the only other thing i see encompassing all the symptoms is hepatitis a which is the one people get by eating contaminated food. the shoulder pain could, indeed, be from cholecystitis, but that is very atypical. cholecystitis would be included with a hepatitis infection. i think the onion rings is a good clue. the scenario doesn't say whether these onion rings were fried or not. if they were fried, were they cooked completely? it does mention "every time she eat them" she gets gi symptoms. so, has she eaten here before? my thinking is. . .if fried, a gall bladder attack is going to occur about 6 hours later; if the onions were fresh to start with and not completely cooked then an attack of hepatitis a is what is going on and every time she has the "onions" at this restaurant she has probably been re-infecting herself. hepatitis a in it's early stages would seem most likely to me since the cholesterol, bilirubin and wbcs are elevated and the wbcs haven't had a chance to develop leukopenia since the disease is probably in its early stages. hepatitis a isn't like the others. it is more of a short-lived illness compared to the viral types.

• http://www.fpnotebook.com/gi/hepatitis/hptsa.htm - hepatitis a, foodborne and passed through (1) infected food handlers, (2) raw shellfish, and (3) fresh produce (green onions, strawberries). your lady has some of its symptoms: nausea and vomiting, diarrhea, abdominal pain, malaise (discomfort, uneasiness, usually indicative of an infection), jaundice, elevated bilirubin. only exception is they are saying the wbcs are leukopenic (reduced)
  
• http://www.cdc.gov/hepatitis/hav.htm - hepatitis a portal - cdc defines a case of hepatitis a as " an acute illness with a) discrete onset of symptoms and b) jaundice or elevated serum aminotransferase levels"