October 2017 Critical Care Case of the Month
Monday, October 2, 2017 at 8:00AM
Rick Robbins, M.D. in abdominal pain, cardiomyopathy, glucocorticoids, hepatitis B, plasma exchange, polyarteritis nodosa, pulmonary edema, tenofovir, testicular pain, treatment

Margaret Ragland, MD1

Carolyn H. Welsh, MD1,2


Pulmonary Sciences and Critical Care Medicine

1University of Colorado Anschutz Medical Campus and 2VA Eastern Colorado Health Care System

Denver, Colorado USA


History of Present Illness

A 42-year-old man with a history of intravenous heroin abuse and chronic hepatitis C infection presents to the emergency department (ED) with recurrent abdominal pain. The pain was dull, epigastric, and did not radiate. The pain worsened after eating, but the timing after eating that it worsened was inconsistent. He had nausea but no vomiting. His bowel movements were normal without constipation, diarrhea, or melena.   

He had presented to another ED multiple times with this same pain over the past six weeks. He does not know what the work-ups revealed, but was discharged from the emergency department each time. He received supportive care including fluids and analgesics, but the pain would always recur a few hours after returning home.

He went to a third ED a few weeks ago with bilateral testicular pain after which he was discharged home with acetaminophen for pain.

Past Medical History, Family History, and Social History

His past medical history is notable for bipolar disorder. He takes no prescribed medications and does not know his family’s medical history. He is a current every day smoker, has no history of heavy alcohol use, and uses intravenous heroin but no other recreational drugs.

Current Medications

Acetaminophen a few times a day for abdominal pain.

Review of Systems

He notes subjective fevers, poor appetite, and an 8 pound unintentional weight loss over the past six weeks.

Physical Exam

Vital signs are notable for hypertension to 158/91 mm Hg. Other vitals are within normal limits.

On exam, he is an ill appearing middle aged man who appears very uncomfortable. His abdomen is nondistended. He has normal bowel sounds and epigastric tenderness with a tender, smooth liver edge palpable just under the costal margin. He has decreased sensation to light touch in his toes with no skin changes. Toes are warm with capillary refill less than two seconds.

Laboratory Evaluation

CBC reveals a leukocytosis to 23,600 cells/mcL with 80% neutrophils; eosinophils are normal. Hemoglobin and platelet counts are normal. Sodium is 128 mmol/L with a bicarbonate of 30 mmol/L and creatinine of 0.64 mmol/L. AST 155 U/L, ALT 137 U/L, with a total bilirubin 1.1 mmol/L. Albumin is 1.8 g/L. INR is 1.9. Urinalysis showed 1+ protein.

What additional laboratory evaluation is indicated at this time? (Click on the correct answer to proceed to the second of six pages)

  1. Acetaminophen level
  2. Hepatitis B viral (HBV) serologies
  3. Lipase
  4. 1 and 3
  5. All of the above

Cite as: Ragland M, Welsh CH. October 2017 critical care case of the month. Southwest J Pulm Crit Care. 2017;15(4):131-7. doi: https://doi.org/10.13175/swjpcc113-17 PDF 

Article originally appeared on SOUTHWEST JOURNAL of PULMONARY & CRITICAL CARE (http://www.swjpcc.com/).
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