Monday, February 4, 2008

Double Entendre

This case is based on a real patient I saw last Tuesday (but I did change details).

I was in the Emergency Department and my preceptor asked me to see a patient in room 17. When I opened the door, I noticed a gaunt-appearing man probably in his forties who began to immediately scream in pain. He was bawling, cursing, howling. I managed to elicit his chief complaint, "It hurts so much," and upon further investigation, I found that he had acute onset steady epigastric pain that began yesterday (he said he stopped drinking several days ago). It was band-like and radiated to the back. He had nausea and vomiting and was restless and agitated. Past medical history was significant for infective endocarditis, osteomyelitis, hepatitis B, and hepatitis C. A police officer recognized him and said he had a record for shoplifting and burglary.

He had tenderness and guarding of the epigastrum. There was no ecchymotic discoloration of the flanks or periumbilical region. But, this was interesting:

What do you think?

Related Questions:
1. If there were ecchymotic discoloration of the flanks or periumbilical region, this would represent two signs, which may be useful for the Boards or wards. What are they?
2. What labs would you like to order?

Image shown under fair use.


Alex said...

Pancreatitis. Cullen's sign and Grey-Turner's sign. Order lipase and amylase.

Craig said...

Double Entendre

This seems like the textbook presentation of acute pancreatitis, most commonly due to alcoholism in men and gallstones in women. Ecchymotic discoloration of the flanks would be Grey-Turner’s sign and that of the periumbilical region would be Cullen’s sign; both represent retroperitoneal bleeding due to pancreatic necrosis (or other etiologies). Lab tests to order include serum amylase and lipase though these tests are not specific or diagnostic. Imaging studies should also be done.

However, it turns out this guy did not have pancreatitis. The image showing track marks on the arm and the history suggesting IV drug use (PMHx and police record) make you think twice about the diagnosis. It turned out when I saw this patient, he was suffering from opiate withdrawal and was drug-seeking. This could be considered malingering or fabricating symptoms for secondary gain.

Source: UpToDate;