Acute Pancreatitis

(M2.GI.17.4694) A 45-year-old man with a history of biliary colic presents with one-day of intractable nausea, vomiting, and abdominal pain radiating to the back. Temperature is 99.7 deg F (37.6 deg C), blood pressure is 102/78 mmHg, pulse is 112/min, and respirations are 22/min. On abdominal exam, he has involuntary guarding and tenderness to palpation in the right upper quadrant and epigastric regions. Laboratory studies show white blood cell count 18,200/uL, alkaline phosphatase 650 U/L, total bilirubin 2.5 mg/dL, amylase 500 U/L, and lipase 1160 U/L. Which of the patient's laboratory findings is associated with increased mortality?

(M2.GI.16.4692) A 39-year-old male presents to the emergency department with acute abdominal pain and anorexia for two days. The patient has an extensive history of alcoholism with a hospitalization four months ago after being brought in by the police department for intoxication. On physical exam vital signs are T 99.0 F, BP 100/68 mmHg, HR 135 bpm, RR 20 rpm, and O2 Sat 100%. Abdominal exam is notable for exquisite tenderness to palpation over the epigastrium and the following finding (Figure A). Therapy for this patient should consist of which of the following?

(M2.HE.15.4672) A 45-year-old homeless man presents to the emergency department acutely intoxicated. He has a history of belligerence and substance abuse and was found today in a local park outdoors in Arizona. His temperature is 97.7°F (36.5°C), blood pressure is 100/66 mmHg, pulse is 130/min, respirations are 26/min, and oxygen saturation is 98% on room air. The patient is responsive to sternal rub and cries out in pain with palpation of his epigastric region. Lower extremity petechiae are noted. Laboratory studies are ordered as seen below.

Hemoglobin: 10 g/dL
Hematocrit: 31%
Leukocyte count: 6,520/mm^3 with normal differential
Platelet count: 51,000/mm^3

Serum:
Na+: 130 mEq/L
Cl-: 101 mEq/L
K+: 3.3 mEq/L
HCO3-: 25 mEq/L
BUN: 20 mg/dL
Glucose: 66 mg/dL
Creatinine: 1.7 mg/dL
Ca2+: 9.2 mg/dL
INR: 2.5

A peripheral smear is ordered as seen in Figure A. The patient is given 2 liters of fluids, and his pulse is subsequently 80/min with a blood pressure of 125/81 mmHg. Which of the following is the most likely diagnosis?

(M2.GI.15.14) A 37-year-old woman with a past medical history diabetes, high cholesterol, hypertension and anxiety complains of rapid-onset, mid-epigastric pain with radiation to the back. She states that she has had a few of these episodes in the past, but this is the worst so far. Her pain is somewhat relieved by sitting forward. Physical examination notes epigastric tenderness without guarding or rebound. Figure A is also noticed on physical examination. Laboratory studies show elevated amylase and lipase. She denies use of alcohol, tobacco, and illicit drugs. A RUQ ultrasound was performed and found to be negative and total and direct bilirubin are normal. Urine toxicology returns negative results and her blood alcohol level is determined to be 0. What is the most likely cause of her current symptoms?