PR_12_13_07.ppt

Professor RoundsProfessor Rounds12/13/0712/13/07

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CC: Abdominal pain. CC: Abdominal pain.

CC: Abdominal pain.CC: Abdominal pain. HPI: A17-year-old female presents with a 12 HPI: A17-year-old female presents with a 12

hour history of abdominal pain, nausea hour history of abdominal pain, nausea and vomiting.and vomiting.

CC: Abdominal pain. CC: Abdominal pain. HPI: A17-year-old female presents with a 12 hour history of abdominal pain, nausea and HPI: A17-year-old female presents with a 12 hour history of abdominal pain, nausea and

vomiting. vomiting.

She was feeling fine until the night before She was feeling fine until the night before presentation when she began to have presentation when she began to have epigastric pain and nausea. Her pain is epigastric pain and nausea. Her pain is dull and persistent and made it difficult for dull and persistent and made it difficult for her to sleep overnight.her to sleep overnight.


vomiting. She was feeling fine until the night before presentation when she began to vomiting. She was feeling fine until the night before presentation when she began to have epigastric pain and nausea. Her pain is dull and persistent and made it difficult have epigastric pain and nausea. Her pain is dull and persistent and made it difficult for her to sleep overnight.for her to sleep overnight.

The patient had 8 episodes of non-bloody, The patient had 8 episodes of non-bloody, non-bilious emesis overnight and decided non-bilious emesis overnight and decided to seek medical care. She felt this way to seek medical care. She felt this way last year when she had strep throat and is last year when she had strep throat and is worried she might have caught it again.worried she might have caught it again.


vomiting. She was feeling fine until the night before presentation when she began to vomiting. She was feeling fine until the night before presentation when she began to have epigastric pain and nausea. Her pain is dull and persistent and made it difficult have epigastric pain and nausea. Her pain is dull and persistent and made it difficult for her to sleep overnight. The patient had 8 episodes of non-bloody, non-bilious for her to sleep overnight. The patient had 8 episodes of non-bloody, non-bilious emesis overnight and decided to seek medical care. She felt this way last year when emesis overnight and decided to seek medical care. She felt this way last year when she had strep throat and is worried she might have caught it again.she had strep throat and is worried she might have caught it again.

ROS: She has been more fatigued than usual for ROS: She has been more fatigued than usual for the past day and also complains of generalized the past day and also complains of generalized aches everywhere. She has not been able to aches everywhere. She has not been able to tolerate liquids since the emesis began, but tolerate liquids since the emesis began, but thinks her UOP has been normal. 2 nights ago thinks her UOP has been normal. 2 nights ago she had one episode of emesis after partying she had one episode of emesis after partying with her friends, but had no further emesis or with her friends, but had no further emesis or nausea until today.nausea until today.



ROS: She has been more fatigued than usual for the past day and also complains of a ROS: She has been more fatigued than usual for the past day and also complains of a generalized aches everywhere. She has not been able to tolerate liquids since the generalized aches everywhere. She has not been able to tolerate liquids since the emesis began, but thinks her UOP has been normal. 2 nights ago she had one emesis began, but thinks her UOP has been normal. 2 nights ago she had one episode of emesis after partying with her friends, but had no further emesis or episode of emesis after partying with her friends, but had no further emesis or nausea until today.nausea until today.

She denies fever, diarrhea, She denies fever, diarrhea, hematochezia, melena, cough, cold, hematochezia, melena, cough, cold, runny nose, sore throat, difficulty runny nose, sore throat, difficulty breathing, syncope, rashes or lesions, breathing, syncope, rashes or lesions, bruising, joint aches, sick contacts or bruising, joint aches, sick contacts or recent travel.recent travel.

CC: Abdominal pain. CC: Abdominal pain. HPI: A17-year-old female presents with a 12 hour history of abdominal pain, nausea and vomiting. HPI: A17-year-old female presents with a 12 hour history of abdominal pain, nausea and vomiting.

She was feeling fine until the night before presentation when she began to have epigastric pain She was feeling fine until the night before presentation when she began to have epigastric pain and nausea. Her pain is dull and persistent and made it difficult for her to sleep overnight. The and nausea. Her pain is dull and persistent and made it difficult for her to sleep overnight. The patient had 8 episodes of non-bloody, non-bilious emesis overnight and decided to seek medical patient had 8 episodes of non-bloody, non-bilious emesis overnight and decided to seek medical care. She felt this way last year when she had strep throat and is worried she might have caught care. She felt this way last year when she had strep throat and is worried she might have caught it again.it again.

ROS: She has been more fatigued than usual for the past day and also complains of a generalized ROS: She has been more fatigued than usual for the past day and also complains of a generalized aches everywhere. She has not been able to tolerate liquids since the emesis began, but thinks aches everywhere. She has not been able to tolerate liquids since the emesis began, but thinks her UOP has been normal. 2 nights ago she had one episode of emesis after partying with her her UOP has been normal. 2 nights ago she had one episode of emesis after partying with her friends, but had no further emesis or nausea until today.friends, but had no further emesis or nausea until today.

She denies fever, diarrhea, hematochezia, melena, cough, cold, runny nose, sore throat, difficulty She denies fever, diarrhea, hematochezia, melena, cough, cold, runny nose, sore throat, difficulty breathing, syncope, rashes or lesions, bruising, joint aches, sick contacts or recent travel.breathing, syncope, rashes or lesions, bruising, joint aches, sick contacts or recent travel.

BHx: Full term, induced vaginal delivery at 6 BHx: Full term, induced vaginal delivery at 6 pounds. Normal prenatal labs, no complications, pounds. Normal prenatal labs, no complications, stayed in the hospital for 2 days.stayed in the hospital for 2 days.

PMHx: A tonsillectomy at age 5. Past injuries PMHx: A tonsillectomy at age 5. Past injuries include a broken thumb, broken leg, bruised ribs include a broken thumb, broken leg, bruised ribs and a concussion. She was in a MVA several and a concussion. She was in a MVA several months ago but had no injuries. No other months ago but had no injuries. No other medical illnesses.medical illnesses.





BHx: Full term, induced vaginal delivery at 6 pounds. Normal prenatal labs, no BHx: Full term, induced vaginal delivery at 6 pounds. Normal prenatal labs, no complications, stayed in the hospital for 2 days.complications, stayed in the hospital for 2 days.

PMHx: A tonsillectomy at age 5. Past injuries include a broken thumb, broken leg, PMHx: A tonsillectomy at age 5. Past injuries include a broken thumb, broken leg, bruised ribs and a concussion. She was in a MVA several months ago, bruised ribs and a concussion. She was in a MVA several months ago,

but had no injuries. No other medical illnesses.but had no injuries. No other medical illnesses.

FHx: Diabetes in a maternal grandfather. FHx: Diabetes in a maternal grandfather. No history of gastrointestinal problems, No history of gastrointestinal problems, IBD, IBS, heart problems, childhood IBD, IBS, heart problems, childhood illnesses, rheumatological conditions, illnesses, rheumatological conditions, migraine or mental illness in the family.migraine or mental illness in the family.





BHx: Full term, induced vaginal delivery at 6 pounds. Normal prenatal labs, no complications, stayed BHx: Full term, induced vaginal delivery at 6 pounds. Normal prenatal labs, no complications, stayed in the hospital for 2 days.in the hospital for 2 days.

PMHx: A tonsillectomy at age 5. Past injuries include a broken thumb, broken leg, bruised ribs and a PMHx: A tonsillectomy at age 5. Past injuries include a broken thumb, broken leg, bruised ribs and a concussion. She was in a MVA several months ago, concussion. She was in a MVA several months ago,

but had no injuries. No other medical illnesses.but had no injuries. No other medical illnesses.FHx: Diabetes in a maternal grandfather. No history of gastrointestinal problems, IBD, IBS, heart FHx: Diabetes in a maternal grandfather. No history of gastrointestinal problems, IBD, IBS, heart

problems, childhood illnesses, rheumatological conditions, migraine or mental illness in the problems, childhood illnesses, rheumatological conditions, migraine or mental illness in the family.family.

SHx: She finished high school last June with grades the B-SHx: She finished high school last June with grades the B-C range and began vocational training in LA, which she C range and began vocational training in LA, which she enjoys. While attending the program, she lives with enjoys. While attending the program, she lives with friends in LA, and with her mother, step-father and two friends in LA, and with her mother, step-father and two dogs in San Diego when she is on a break. She states dogs in San Diego when she is on a break. She states that she has a good relationship with her mother and that she has a good relationship with her mother and stepfather and has not seen her father in many months. stepfather and has not seen her father in many months.





BHx: Full term, induced vaginal delivery at 6 pounds. Normal prenatal labs, no complications, stayed BHx: Full term, induced vaginal delivery at 6 pounds. Normal prenatal labs, no complications, stayed in the hospital for 2 days.in the hospital for 2 days.

PMHx: A tonsillectomy at age 5. Past injuries include a broken thumb, broken leg, bruised ribs and a PMHx: A tonsillectomy at age 5. Past injuries include a broken thumb, broken leg, bruised ribs and a concussion. She was in a MVA several months ago, concussion. She was in a MVA several months ago,

but had no injuries. No other medical illnesses.but had no injuries. No other medical illnesses.FHx: Diabetes in a maternal grandfather. No history of gastrointestinal problems, IBD, IBS, heart FHx: Diabetes in a maternal grandfather. No history of gastrointestinal problems, IBD, IBS, heart


SHx: She finished high school last June with grades the B-C range and began vocational training in SHx: She finished high school last June with grades the B-C range and began vocational training in LA, which she enjoys. While attending the program, she lives with friends in LA, and with her LA, which she enjoys. While attending the program, she lives with friends in LA, and with her mother, step-father and two dogs in San Diego when she is on a break. She states that she has mother, step-father and two dogs in San Diego when she is on a break. She states that she has a good relationship with her mother and stepfather and has not seen her father in many months. a good relationship with her mother and stepfather and has not seen her father in many months.

She has a history of binge drinking for about 9 months; she drinks 3 to She has a history of binge drinking for about 9 months; she drinks 3 to 4 times a week, 5 to 6 drinks of beer or hard alcohol. Over the past 4 times a week, 5 to 6 drinks of beer or hard alcohol. Over the past 3 months during this program, she has not had anything to drink 3 months during this program, she has not had anything to drink until the week that she came home. But during this past week she until the week that she came home. But during this past week she has been out partying with her friends almost every night.has been out partying with her friends almost every night.

She smokes one pack of cigarettes every 2 weeks and has a history of She smokes one pack of cigarettes every 2 weeks and has a history of trying marijuana at 14 years of age and has not used it since then. trying marijuana at 14 years of age and has not used it since then. She denies any other drug use. She denies any other drug use.

CC: Abdominal pain. CC: Abdominal pain. HPI: A17-year-old female presents with a 12 hour history of abdominal pain, nausea and vomiting. She was feeling HPI: A17-year-old female presents with a 12 hour history of abdominal pain, nausea and vomiting. She was feeling

fine until the night before presentation when she began to have epigastric pain and nausea. Her pain is dull and fine until the night before presentation when she began to have epigastric pain and nausea. Her pain is dull and persistent and made it difficult for her to sleep overnight. The patient had 8 episodes of non-bloody, non-bilious persistent and made it difficult for her to sleep overnight. The patient had 8 episodes of non-bloody, non-bilious emesis overnight and decided to seek medical care. She felt this way last year when she had strep throat and is emesis overnight and decided to seek medical care. She felt this way last year when she had strep throat and is worried she might have caught it again.worried she might have caught it again.

ROS: She has been more fatigued than usual for the past day and also complains of a generalized aches ROS: She has been more fatigued than usual for the past day and also complains of a generalized aches everywhere. She has not been able to tolerate liquids since the emesis began, but thinks her UOP has been everywhere. She has not been able to tolerate liquids since the emesis began, but thinks her UOP has been normal. 2 nights ago she had one episode of emesis after partying with her friends, but had no further emesis or normal. 2 nights ago she had one episode of emesis after partying with her friends, but had no further emesis or nausea until today.nausea until today.

She denies fever, diarrhea, hematochezia, melena, cough, cold, runny nose, sore throat, difficulty breathing, syncope, She denies fever, diarrhea, hematochezia, melena, cough, cold, runny nose, sore throat, difficulty breathing, syncope, rashes or lesions, bruising, joint aches, sick contacts or recent travel.rashes or lesions, bruising, joint aches, sick contacts or recent travel.

BHx: Full term, induced vaginal delivery at 6 pounds. Normal prenatal labs, no complications, stayed in the hospital BHx: Full term, induced vaginal delivery at 6 pounds. Normal prenatal labs, no complications, stayed in the hospital for 2 days.for 2 days.

PMHx: A tonsillectomy at age 5. Past injuries include a broken thumb, broken leg, bruised ribs and a concussion. She PMHx: A tonsillectomy at age 5. Past injuries include a broken thumb, broken leg, bruised ribs and a concussion. She was in a MVA several months ago, was in a MVA several months ago,

but had no injuries. No other medical illnesses.but had no injuries. No other medical illnesses.FHx: Diabetes in a maternal grandfather. No history of gastrointestinal problems, IBD, IBS, heart problems, childhood FHx: Diabetes in a maternal grandfather. No history of gastrointestinal problems, IBD, IBS, heart problems, childhood

illnesses, rheumatological conditions, migraine or mental illness in the family.illnesses, rheumatological conditions, migraine or mental illness in the family.SHx: She finished high school last June with grades the B-C range and began vocational training in LA, which she SHx: She finished high school last June with grades the B-C range and began vocational training in LA, which she

enjoys. While attending the program, she lives with friends in LA, and with her mother, step-father and two dogs enjoys. While attending the program, she lives with friends in LA, and with her mother, step-father and two dogs in San Diego when she is on a break. She states that she has a good relationship with her mother and stepfather in San Diego when she is on a break. She states that she has a good relationship with her mother and stepfather and has not seen her father in many months. and has not seen her father in many months.

She has a history of binge drinking for about 9 months; she drinks 3 to 4 times a week, 5 to 6 drinks of beer or hard She has a history of binge drinking for about 9 months; she drinks 3 to 4 times a week, 5 to 6 drinks of beer or hard alcohol. Over the past 3 months during this program, she has not had anything to drink until the week that she alcohol. Over the past 3 months during this program, she has not had anything to drink until the week that she came home. But during this past week she has been out partying with her friends almost every night.came home. But during this past week she has been out partying with her friends almost every night.

She smokes one pack of cigarettes every 2 weeks and has a history of trying marijuana at 14 years of age and has not She smokes one pack of cigarettes every 2 weeks and has a history of trying marijuana at 14 years of age and has not used it since then. She denies any other drug use. used it since then. She denies any other drug use.

She has been sexually active recently, until last week, when she and She has been sexually active recently, until last week, when she and her boyfriend broke up. She has not been diagnosed with any her boyfriend broke up. She has not been diagnosed with any STDs in the pastSTDs in the past

She endorses recent irritability, sadness and insomnia. For the past She endorses recent irritability, sadness and insomnia. For the past week she has used tylenol PM to fall asleep. She denies week she has used tylenol PM to fall asleep. She denies anhedonia, concentration difficulties, being depressed or having anhedonia, concentration difficulties, being depressed or having suicidal ideation.suicidal ideation.



ROS: She has been more fatigued than usual for the past day and also complains of a generalized aches everywhere. She has not been able ROS: She has been more fatigued than usual for the past day and also complains of a generalized aches everywhere. She has not been able to tolerate liquids since the emesis began, but thinks her UOP has been normal. 2 nights ago she had one episode of emesis after to tolerate liquids since the emesis began, but thinks her UOP has been normal. 2 nights ago she had one episode of emesis after partying with her friends, but had no further emesis or nausea until today.partying with her friends, but had no further emesis or nausea until today.

She denies fever, diarrhea, hematochezia, melena, cough, cold, runny nose, sore throat, difficulty breathing, syncope, rashes or lesions, She denies fever, diarrhea, hematochezia, melena, cough, cold, runny nose, sore throat, difficulty breathing, syncope, rashes or lesions, bruising, joint aches, sick contacts or recent travel.bruising, joint aches, sick contacts or recent travel.

BHx: Full term, induced vaginal delivery at 6 pounds. Normal prenatal labs, no complications, stayed in the hospital for 2 days.BHx: Full term, induced vaginal delivery at 6 pounds. Normal prenatal labs, no complications, stayed in the hospital for 2 days.PMHx: A tonsillectomy at age 5. Past injuries include a broken thumb, broken leg, bruised ribs and a concussion. She was in a MVA several PMHx: A tonsillectomy at age 5. Past injuries include a broken thumb, broken leg, bruised ribs and a concussion. She was in a MVA several

months ago, months ago, but had no injuries. No other medical illnesses.but had no injuries. No other medical illnesses.FHx: Diabetes in a maternal grandfather. No history of gastrointestinal problems, IBD, IBS, heart FHx: Diabetes in a maternal grandfather. No history of gastrointestinal problems, IBD, IBS, heart


SHx: She finished high school last June with grades the B-C range and began vocational training in SHx: She finished high school last June with grades the B-C range and began vocational training in LA, which she enjoys. While attending the program, she lives with friends in LA, and with her LA, which she enjoys. While attending the program, she lives with friends in LA, and with her mother, step-father and two dogs in San Diego when she is on a break. She states that she has mother, step-father and two dogs in San Diego when she is on a break. She states that she has a good relationship with her mother and stepfather and has not seen her father in many months. a good relationship with her mother and stepfather and has not seen her father in many months.

She has a history of binge drinking for about 9 months; she drinks 3 to 4 times a week, 5 to 6 drinks She has a history of binge drinking for about 9 months; she drinks 3 to 4 times a week, 5 to 6 drinks of beer or hard alcohol. Over the past 3 months during this program, she has not had anything to of beer or hard alcohol. Over the past 3 months during this program, she has not had anything to drink until the week that she came home. But during this past week she has been out partying drink until the week that she came home. But during this past week she has been out partying with her friends almost every night.with her friends almost every night.

She smokes one pack of cigarettes every 2 weeks and has a history of trying marijuana at 14 years of She smokes one pack of cigarettes every 2 weeks and has a history of trying marijuana at 14 years of age and has not used it since then. She denies any other drug use. age and has not used it since then. She denies any other drug use.

She has been sexually active recently, until last week, when she and her boyfriend broke up. She She has been sexually active recently, until last week, when she and her boyfriend broke up. She has not been diagnosed with any STDs in the pasthas not been diagnosed with any STDs in the past

She endorses recent irritability, sadness and insomnia. For the past week she has used tylenol PM She endorses recent irritability, sadness and insomnia. For the past week she has used tylenol PM to fall asleep. She denies anhedonia, concentration difficulties, being depressed or having to fall asleep. She denies anhedonia, concentration difficulties, being depressed or having suicidal ideation.suicidal ideation.

MEDS: Ortho tri-cyclin, Pepto-Bismol & Tylenol PM.MEDS: Ortho tri-cyclin, Pepto-Bismol & Tylenol PM.

CC: Abdominal pain. CC: Abdominal pain. HPI: A17-year-old female presents with a 12 hour history of abdominal pain, nausea and vomiting. She was feeling HPI: A17-year-old female presents with a 12 hour history of abdominal pain, nausea and vomiting. She was feeling

fine until the night before presentation when she began to have epigastric pain and nausea. Her pain is dull and fine until the night before presentation when she began to have epigastric pain and nausea. Her pain is dull and persistent and made it difficult for her to sleep overnight. The patient had 8 episodes of non-bloody, non-bilious persistent and made it difficult for her to sleep overnight. The patient had 8 episodes of non-bloody, non-bilious emesis overnight and decided to seek medical care. She felt this way last year when she had strep throat and is emesis overnight and decided to seek medical care. She felt this way last year when she had strep throat and is worried she might have caught it again.worried she might have caught it again.

ROS: She has been more fatigued than usual for the past day and also complains of a generalized aches everywhere. She has not been able to tolerate ROS: She has been more fatigued than usual for the past day and also complains of a generalized aches everywhere. She has not been able to tolerate liquids since the emesis began, but thinks her UOP has been normal. 2 nights ago she had one episode of emesis after partying with her friends, but liquids since the emesis began, but thinks her UOP has been normal. 2 nights ago she had one episode of emesis after partying with her friends, but had no further emesis or nausea until today.had no further emesis or nausea until today.

She denies fever, diarrhea, hematochezia, melena, cough, cold, runny nose, sore throat, difficulty breathing, syncope, rashes or lesions, bruising, joint aches, She denies fever, diarrhea, hematochezia, melena, cough, cold, runny nose, sore throat, difficulty breathing, syncope, rashes or lesions, bruising, joint aches, sick contacts or recent travel.sick contacts or recent travel.

BHx: Full term, induced vaginal delivery at 6 pounds. Normal prenatal labs, no complications, stayed in the hospital for 2 days.BHx: Full term, induced vaginal delivery at 6 pounds. Normal prenatal labs, no complications, stayed in the hospital for 2 days.PMHx: A tonsillectomy at age 5. Past injuries include a broken thumb, broken leg, bruised ribs and a concussion. She was in a MVA several months ago, PMHx: A tonsillectomy at age 5. Past injuries include a broken thumb, broken leg, bruised ribs and a concussion. She was in a MVA several months ago, but had no injuries. No other medical illnesses.but had no injuries. No other medical illnesses.FHx: Diabetes in a maternal grandfather. No history of gastrointestinal problems, IBD, IBS, heart problems, childhood FHx: Diabetes in a maternal grandfather. No history of gastrointestinal problems, IBD, IBS, heart problems, childhood




She smokes one pack of cigarettes every 2 weeks and has a history of trying marijuana at 14 years of age and has not She smokes one pack of cigarettes every 2 weeks and has a history of trying marijuana at 14 years of age and has not used it since then. She denies any other drug use. used it since then. She denies any other drug use.

She has been sexually active recently, until last week, when she and her boyfriend broke up. She has not been She has been sexually active recently, until last week, when she and her boyfriend broke up. She has not been diagnosed with any STDs in the pastdiagnosed with any STDs in the past

She endorses recent irritability, sadness and insomnia. For the past week she has used tylenol PM to fall asleep. She She endorses recent irritability, sadness and insomnia. For the past week she has used tylenol PM to fall asleep. She denies anhedonia, concentration difficulties, being depressed or having suicidal ideation.denies anhedonia, concentration difficulties, being depressed or having suicidal ideation.

MEDS: Ortho tri-cyclin, Pepto-Bismol & Tylenol PM.MEDS: Ortho tri-cyclin, Pepto-Bismol & Tylenol PM.

Nutrition: She eats a varied diet, does not have concerns Nutrition: She eats a varied diet, does not have concerns about her weight and denies any history of binging, about her weight and denies any history of binging, purging or eating disorders.purging or eating disorders.

Devo: She met all milestones (per mom). Menarche at age Devo: She met all milestones (per mom). Menarche at age 12.12.



ROS: She has been more fatigued than usual for the past day and also complains of a generalized aches everywhere. She has not been able ROS: She has been more fatigued than usual for the past day and also complains of a generalized aches everywhere. She has not been able to tolerate liquids since the emesis began, but thinks her UOP has been normal. 2 nights ago she had one episode of emesis after to tolerate liquids since the emesis began, but thinks her UOP has been normal. 2 nights ago she had one episode of emesis after partying with her friends, but had no further emesis or nausea until today.partying with her friends, but had no further emesis or nausea until today.

She denies fever, diarrhea, hematochezia, melena, cough, cold, runny nose, sore throat, difficulty breathing, syncope, rashes or lesions, She denies fever, diarrhea, hematochezia, melena, cough, cold, runny nose, sore throat, difficulty breathing, syncope, rashes or lesions, bruising, joint aches, sick contacts or recent travel.bruising, joint aches, sick contacts or recent travel.

BHx: Full term, induced vaginal delivery at 6 pounds. Normal prenatal labs, no complications, stayed in the hospital for 2 days.BHx: Full term, induced vaginal delivery at 6 pounds. Normal prenatal labs, no complications, stayed in the hospital for 2 days.PMHx: A tonsillectomy at age 5. Past injuries include a broken thumb, broken leg, bruised ribs and a concussion. She was in a MVA several PMHx: A tonsillectomy at age 5. Past injuries include a broken thumb, broken leg, bruised ribs and a concussion. She was in a MVA several

months ago, months ago, but had no injuries. No other medical illnesses.but had no injuries. No other medical illnesses.FHx: Diabetes in a maternal grandfather. No history of gastrointestinal problems, IBD, IBS, heart problems, childhood FHx: Diabetes in a maternal grandfather. No history of gastrointestinal problems, IBD, IBS, heart problems, childhood




She smokes one pack of cigarettes every 2 weeks and has a history of trying marijuana at 14 years of She smokes one pack of cigarettes every 2 weeks and has a history of trying marijuana at 14 years of age and has not used it since then. She denies any other drug use. age and has not used it since then. She denies any other drug use.

She has been sexually active recently, until last week, when she and her boyfriend broke up. She She has been sexually active recently, until last week, when she and her boyfriend broke up. She has not been diagnosed with any STDs in the pasthas not been diagnosed with any STDs in the past

She endorses recent irritability, sadness and insomnia. For the past week she has used tylenol PM She endorses recent irritability, sadness and insomnia. For the past week she has used tylenol PM to fall asleep. She denies anhedonia, concentration difficulties, being depressed or having to fall asleep. She denies anhedonia, concentration difficulties, being depressed or having suicidal ideation.suicidal ideation.

MEDS: Ortho tri-cyclin, Pepto-Bismol & Tylenol PM.MEDS: Ortho tri-cyclin, Pepto-Bismol & Tylenol PM.Nutrition: She eats a varied diet and does not have concerns about her weight and denies any Nutrition: She eats a varied diet and does not have concerns about her weight and denies any

history of binging, purging or eating disorders.history of binging, purging or eating disorders.Devo: She met all milestones (per mom). Menarche at age 12.Devo: She met all milestones (per mom). Menarche at age 12.

Immunizations:Up-to-date. Allergies: Amoxicillin causes diarrheaImmunizations:Up-to-date. Allergies: Amoxicillin causes diarrhea

CC: Abdominal pain. CC: Abdominal pain. HPI: A17-year-old female presents with a 12 hour history of abdominal pain, nausea and vomiting. She HPI: A17-year-old female presents with a 12 hour history of abdominal pain, nausea and vomiting. She

was feeling fine until the night before presentation when she began to have epigastric pain and was feeling fine until the night before presentation when she began to have epigastric pain and nausea. Her pain is dull and persistent and made it difficult for her to sleep overnight. The patient had nausea. Her pain is dull and persistent and made it difficult for her to sleep overnight. The patient had 8 episodes of non-bloody, non-bilious emesis overnight and decided to seek medical care. She felt this 8 episodes of non-bloody, non-bilious emesis overnight and decided to seek medical care. She felt this way last year when she had strep throat and is worried she might have caught it again.way last year when she had strep throat and is worried she might have caught it again.

ROS: She has been more fatigued than usual for the past day and also complains of a generalized aches everywhere. She has not been able to ROS: She has been more fatigued than usual for the past day and also complains of a generalized aches everywhere. She has not been able to tolerate liquids since the emesis began, but thinks her UOP has been normal. 2 nights ago she had one episode of emesis after partying with tolerate liquids since the emesis began, but thinks her UOP has been normal. 2 nights ago she had one episode of emesis after partying with her friends, but had no further emesis or nausea until today.her friends, but had no further emesis or nausea until today.

She denies fever, diarrhea, hematochezia, melena, cough, cold, runny nose, sore throat, difficulty breathing, syncope, rashes or lesions, bruising, joint She denies fever, diarrhea, hematochezia, melena, cough, cold, runny nose, sore throat, difficulty breathing, syncope, rashes or lesions, bruising, joint aches, sick contacts or recent travel.aches, sick contacts or recent travel.

BHx: Full term, induced vaginal delivery at 6 pounds. Normal prenatal labs, no complications, stayed in the hospital for 2 days.BHx: Full term, induced vaginal delivery at 6 pounds. Normal prenatal labs, no complications, stayed in the hospital for 2 days.PMHx: A tonsillectomy at age 5. Past injuries include a broken thumb, broken leg, bruised ribs and a concussion. She was in a MVA several months PMHx: A tonsillectomy at age 5. Past injuries include a broken thumb, broken leg, bruised ribs and a concussion. She was in a MVA several months

ago, ago, but had no injuries. No other medical illnesses.but had no injuries. No other medical illnesses.FHx: Diabetes in a maternal grandfather. No history of gastrointestinal problems, IBD, IBS, heart problems, childhood FHx: Diabetes in a maternal grandfather. No history of gastrointestinal problems, IBD, IBS, heart problems, childhood

illnesses, rheumatological conditions, migraine or mental illness in the family.illnesses, rheumatological conditions, migraine or mental illness in the family.SHx: She finished high school last June with grades the B-C range and began vocational training in LA, which she enjoys. SHx: She finished high school last June with grades the B-C range and began vocational training in LA, which she enjoys.

While attending the program, she lives with friends in LA, and with her mother, step-father and two dogs in San Diego While attending the program, she lives with friends in LA, and with her mother, step-father and two dogs in San Diego when she is on a break. She states that she has a good relationship with her mother and stepfather and has not seen when she is on a break. She states that she has a good relationship with her mother and stepfather and has not seen her father in many months. her father in many months.

She has a history of binge drinking for about 9 months; she drinks 3 to 4 times a week, 5 to 6 drinks of beer or hard alcohol. She has a history of binge drinking for about 9 months; she drinks 3 to 4 times a week, 5 to 6 drinks of beer or hard alcohol. Over the past 3 months during this program, she has not had anything to drink until the week that she came home. But Over the past 3 months during this program, she has not had anything to drink until the week that she came home. But during this past week she has been out partying with her friends almost every night.during this past week she has been out partying with her friends almost every night.

She smokes one pack of cigarettes every 2 weeks and has a history of trying marijuana at 14 years of age She smokes one pack of cigarettes every 2 weeks and has a history of trying marijuana at 14 years of age and has not used it since then. She denies any other drug use. and has not used it since then. She denies any other drug use.

She has been sexually active recently, until last week, when she and her boyfriend broke up. She has not She has been sexually active recently, until last week, when she and her boyfriend broke up. She has not been diagnosed with any STDs in the pastbeen diagnosed with any STDs in the past

She endorses recent irritability, sadness and insomnia. For the past week she has used tylenol PM to fall She endorses recent irritability, sadness and insomnia. For the past week she has used tylenol PM to fall asleep. She denies anhedonia, concentration difficulties, being depressed or having suicidal ideation.asleep. She denies anhedonia, concentration difficulties, being depressed or having suicidal ideation.

MEDS: Ortho tri-cyclin, Pepto-Bismol & Tylenol PM.MEDS: Ortho tri-cyclin, Pepto-Bismol & Tylenol PM.Nutrition: She eats a varied diet and does not have concerns about her weight and denies any history of Nutrition: She eats a varied diet and does not have concerns about her weight and denies any history of

binging, purging or eating disorders.binging, purging or eating disorders.Devo: She met all milestones (per mom). Menarche at age 12.Devo: She met all milestones (per mom). Menarche at age 12.Immunizations:Up-to-date. Allergies: Amoxicillin causes diarrheaImmunizations:Up-to-date. Allergies: Amoxicillin causes diarrhea

End HPIEnd HPI

Physical Exam:Physical Exam:

Physical Exam:Physical Exam:Vitals: Temperature 36.8, heart rate 80, Vitals: Temperature 36.8, heart rate 80,

respiratory rate 20, blood pressure 121/79.respiratory rate 20, blood pressure 121/79.Wt 48.3 kg (15%) Ht 139 cm (3%)Wt 48.3 kg (15%) Ht 139 cm (3%)

Physical Exam:Physical Exam:Vitals: Temperature 36.8, heart rate 80, respiratory rate 20, blood pressure 121/79.Vitals: Temperature 36.8, heart rate 80, respiratory rate 20, blood pressure 121/79.Wt 48.3 kg (15%) Ht 139 cm (3%)Wt 48.3 kg (15%) Ht 139 cm (3%)

General: Petite Hispanic girl, lying in bed. General: Petite Hispanic girl, lying in bed. She is awake and tired appearing, but She is awake and tired appearing, but alert and oriented. alert and oriented.

Physical Exam:Physical Exam:Vtials: Temperature 36.8, heart rate 80, respiratory rate 20, blood pressure 121/79.Vtials: Temperature 36.8, heart rate 80, respiratory rate 20, blood pressure 121/79.Wt 48.3 kg (15%) Ht 139 cm (3%)Wt 48.3 kg (15%) Ht 139 cm (3%)General: Petite Hispanic girl, lying in bed. She is awake and tired appearing, but alert General: Petite Hispanic girl, lying in bed. She is awake and tired appearing, but alert

and oriented. and oriented.

HEENT: Normocephalic, atraumatic. HEENT: Normocephalic, atraumatic. Conjunctivae injected, no icterus, PERRL. Conjunctivae injected, no icterus, PERRL. NP patent, moist mucous membranes. NP patent, moist mucous membranes. Oropharynx clear, no erythema, exudates Oropharynx clear, no erythema, exudates or lesions.or lesions.

Neck: Supple. No lymphadenopathy.Neck: Supple. No lymphadenopathy.


and oriented. and oriented. HEENT: Normocephalic, atraumatic. Conjunctivae injected, no icterus, PERRL. NP HEENT: Normocephalic, atraumatic. Conjunctivae injected, no icterus, PERRL. NP

patent, moist mucous membranes. Oropharynx clear, no erythema, exudates or patent, moist mucous membranes. Oropharynx clear, no erythema, exudates or lesions.lesions.

Neck: Supple. No lymphadenopathy.Neck: Supple. No lymphadenopathy.

Resp: Clear to auscultation bilaterally.Resp: Clear to auscultation bilaterally.CV: Regular rate and rhythm, normal S1 CV: Regular rate and rhythm, normal S1

and S2. No murmurs, rubs or gallops.and S2. No murmurs, rubs or gallops.




Neck: Supple. No lymphadenopathy.Neck: Supple. No lymphadenopathy.Resp: Clear to auscultation bilaterally.Resp: Clear to auscultation bilaterally.CV: Regular rate and rhythm, normal S1 and S2. No murmurs, rubs or gallops.CV: Regular rate and rhythm, normal S1 and S2. No murmurs, rubs or gallops.

ABD: Positive bowel sounds. Soft, ABD: Positive bowel sounds. Soft, nondistended. She has a palpable liver nondistended. She has a palpable liver edge 1cm below the costal margin, that is edge 1cm below the costal margin, that is tender and some tenderness in the tender and some tenderness in the epigastrium with deep palpation. epigastrium with deep palpation.




Neck: Supple. No lymphadenopathy.Neck: Supple. No lymphadenopathy.Resp: Clear to auscultation bilaterally.Resp: Clear to auscultation bilaterally.CV: Regular rate and rhythm, normal S1 and S2. No murmurs, rubs or gallops.CV: Regular rate and rhythm, normal S1 and S2. No murmurs, rubs or gallops.ABD: Positive bowel sounds. Soft, nondistended. She has a palpable liver edge 1 cm ABD: Positive bowel sounds. Soft, nondistended. She has a palpable liver edge 1 cm

below the costal margin, that is tender and some tenderness in the epigastrium with below the costal margin, that is tender and some tenderness in the epigastrium with deep palpation. deep palpation.

GU: Tanner V, normal rectal exam, hemoccult GU: Tanner V, normal rectal exam, hemoccult negative.negative.

EXT: Warm and well perfused. No cyanosis, EXT: Warm and well perfused. No cyanosis, clubbing or edema. CR 1 sec.clubbing or edema. CR 1 sec.




Neck: Supple. No lymphadenopathy.Neck: Supple. No lymphadenopathy.Resp: Clear to auscultation bilaterally.Resp: Clear to auscultation bilaterally.CV: Regular rate and rhythm, normal S1 and S2. No murmurs, rubs or gallops.CV: Regular rate and rhythm, normal S1 and S2. No murmurs, rubs or gallops.ABD: Positive bowel sounds. Soft, nondistended. She has a palpable liver edge that is ABD: Positive bowel sounds. Soft, nondistended. She has a palpable liver edge that is

tender and some tenderness in the epigastrium with deep palpation. tender and some tenderness in the epigastrium with deep palpation. GU: Tanner V, normal rectal exam, hemoccult negative.GU: Tanner V, normal rectal exam, hemoccult negative.EXT: Warm and well perfused. No cyanosis, clubbing or edema. CR 1 sec.EXT: Warm and well perfused. No cyanosis, clubbing or edema. CR 1 sec.

Derm: No rashes, jaundice, ecchymosis or Derm: No rashes, jaundice, ecchymosis or lesions. She has multiple tattoos on the lesions. She has multiple tattoos on the abdomen.abdomen.

Neuro: Cranial nerves II through XII are intact. Neuro: Cranial nerves II through XII are intact. DTRs 2+ bilaterally at the patella, strenght 5/5 in DTRs 2+ bilaterally at the patella, strenght 5/5 in all 4 extremities, sensation to light touch intact all 4 extremities, sensation to light touch intact throughout. No pronator drift. Normal finger-to-throughout. No pronator drift. Normal finger-to-nose.nose.




Neck: Supple. No lymphadenopathy.Neck: Supple. No lymphadenopathy.Resp: Clear to auscultation bilaterally.Resp: Clear to auscultation bilaterally.CV: Regular rate and rhythm, normal S1 and S2. No murmurs, rubs or gallops.CV: Regular rate and rhythm, normal S1 and S2. No murmurs, rubs or gallops.ABD: Positive bowel sounds. Soft, nondistended. She has a palpable liver edge that is ABD: Positive bowel sounds. Soft, nondistended. She has a palpable liver edge that is

tender and some tenderness in the epigastrium with deep palpation. tender and some tenderness in the epigastrium with deep palpation. GU: Tanner V, normal rectal exam, hemoccult negative.GU: Tanner V, normal rectal exam, hemoccult negative.EXT: Warm and well perfused. No cyanosis, clubbing or edema. CR 1 sec.EXT: Warm and well perfused. No cyanosis, clubbing or edema. CR 1 sec.Derm: No rashes, jaundice, ecchymosis or lesions. She has multiple tattoos on the Derm: No rashes, jaundice, ecchymosis or lesions. She has multiple tattoos on the

abdomen.abdomen.Neuro: Cranial nerves II through XII are intact. DTRs 2+ bilaterally at the patella, Neuro: Cranial nerves II through XII are intact. DTRs 2+ bilaterally at the patella,

strenght 5/5 in all 4 extremities, sensation to light touch intact throughout. No pronator strenght 5/5 in all 4 extremities, sensation to light touch intact throughout. No pronator drift. Normal finger-to-nose.drift. Normal finger-to-nose.

End HPIEnd HPI

ResultsResults

ResultsResults

12.9

10.2 138 37.6

S 84 B 7 L 5 M 4

MCV 85.9 RBC Morph: Normal

ResultsResults

12.9

10.2 138 37.6

S 84 B 7 L 5 M 4


1 94 13 138

3.1 24 0.7

TP 7.8 ALB 4.6 Ca 9.7

AST 20,921 ALT 11,915

ALP 84 TBili 2.7 Db 0.8

Lipase 263

ResultsResults

12.9

10.2 138 37.6

S 84 B 7 L 5 M 4


1 94 13 138

3.1 24 0.7

TP 7.8 ALB 4.6 Ca 9.7

AST 20,921 ALT 11,915


Lipase 263

PT 52.5 PTT 53 INR 5.8

ResultsResults

12.9

10.2 138 37.6

S 84 B 7 L 5 M 4


1 94 13 138

3.1 24 0.7

TP 7.8 ALB 4.6 Ca 9.7

AST 20,921 ALT 11,915


Lipase 263 U-hcg: neg

UA: Sg 1.025, pH 6, 2+ prot, 2+ bld, Ketones mod, Leuk est neg, Nit neg

Micro: 5 WBCs, 8 RBCs

No casts or bacteria

PT 52.5 PTT 53 INR 5.8

ResultsResultsVBG: 7.34/38/47/-4.7VBG: 7.34/38/47/-4.7

ResultsResultsVBG: 7.34/38/47/-4.7VBG: 7.34/38/47/-4.7

Utox: negUtox: neg

Tylenol level: 14Tylenol level: 14ASA: undetectableASA: undetectable

Patient CoursePatient CourseAfter further questioning, the patient admitted to After further questioning, the patient admitted to taking a handful of Tylenol PM pills (~30 pills), taking a handful of Tylenol PM pills (~30 pills), 2 days before presentation, to fall asleep after 2 days before presentation, to fall asleep after she had been out drinking with friends.she had been out drinking with friends.She strongly denies any suicidal ideationShe strongly denies any suicidal ideationA few hours after taking the medicine, she had A few hours after taking the medicine, she had an episode of emesis (previously mentioned) an episode of emesis (previously mentioned) that contained several pill fragments.that contained several pill fragments.The patient felt better and did not mention the The patient felt better and did not mention the ingestion.ingestion.Her mother saw the emesis and believed the Her mother saw the emesis and believed the patient had thrown up all the medication she had patient had thrown up all the medication she had takentaken

The patient is 48 hours post ingestion at the time of diagnosis.

Hospital CourseHospital CourseThe patient was immediately started on Mucomyst The patient was immediately started on Mucomyst and IVFand IVFShe was admitted to IMU but quickly moved to the She was admitted to IMU but quickly moved to the PICU for fulminant liver failurePICU for fulminant liver failureTransplant surgery was consulted and a Transplant surgery was consulted and a preliminary transplant work up was initiatedpreliminary transplant work up was initiated Further lab studies:Further lab studies: Hepatitis serologies (HBsag, Hep A IgM, Hep BC Ab Hepatitis serologies (HBsag, Hep A IgM, Hep BC Ab

and Hep C Ab) were all negativeand Hep C Ab) were all negative Alpha-1-Anti-trypsin level and genotyping were normalAlpha-1-Anti-trypsin level and genotyping were normal Alfa-fetoprotein level was normalAlfa-fetoprotein level was normal

Hospital CourseHospital CourseDuring her 3 day PICU stay the patient had During her 3 day PICU stay the patient had hypotension requiring multiple fluid boluses and hypotension requiring multiple fluid boluses and pressorspressorsShe also developed anuria and acute renal She also developed anuria and acute renal failure (ATN on renal biopsy), requiring 5 failure (ATN on renal biopsy), requiring 5 courses of dialysis and 6 weeks of high dose courses of dialysis and 6 weeks of high dose steroidssteroidsThe patient stabilized and transferred back to The patient stabilized and transferred back to IMU where she was followed by pediatrics and IMU where she was followed by pediatrics and psychiatry.psychiatry.

Hospital CourseHospital CourseAfter a 13 day hospital stay, the patient was After a 13 day hospital stay, the patient was discharged homedischarged home D/C labs: BUN 17, Cr 3.6, AST 49, ALT 192, PT 13, D/C labs: BUN 17, Cr 3.6, AST 49, ALT 192, PT 13,

PTT 27, INR 1.1PTT 27, INR 1.1

The patient continues to have normal liver The patient continues to have normal liver function and was cleared by Gastroenterology 1 function and was cleared by Gastroenterology 1 month after her overdosemonth after her overdoseThe patient is followed at renal clinic and her The patient is followed at renal clinic and her renal function has now normalizedrenal function has now normalizedShe continues to be followed by psychiatryShe continues to be followed by psychiatry

Professor Rounds 12/13/07Slide 2Slide 3Slide 4Slide 5Slide 6Slide 7Slide 8Slide 9Slide 10Slide 11Slide 12Slide 13Slide 14Slide 15Slide 16Slide 17Slide 18Slide 19Slide 20Slide 21Slide 22Slide 23Slide 24Slide 25ResultsSlide 27Slide 28Slide 29Slide 30Slide 31Slide 32Patient CourseSlide 34Hospital CourseSlide 36Slide 37

PR_12_13_07.ppt

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