The Case

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ACEP Now: Vol 37 – No 07 – July 2018

ILLUSTRATION: Chris Whissen & shutterstock.com

The patient is a 17-year-old non-English-speaking Bengali female with no past medical history who presented to the pediatric emergency department at 12:30 a.m. with complaints of abdominal pain, vomiting, and headache that began earlier that evening. She is accompanied by her mother, younger sister, and a male neighbor who was asked to come to help translate. She describes the abdominal pain as diffuse in nature without localization, with more than 15 episodes of non-bloody, non-bilious emesis. There is no food exposure to account for her symptoms as she has not had anything to eat that day. Her last menstrual period was about 20 days prior to ED visit and was normal. She denies recent travel, fever, chills, urinary symptoms, diarrhea, sick contacts, or taking medications for her symptoms.

On exam, she appears pale and uncomfortable, with dry mucous membranes. However, she is awake, alert, and oriented, with a Glasgow Coma Scale score of 15. The abdominal exam reveals mild diffuse abdominal tenderness without radiation, rigidity, or guarding. IV access is obtained, and blood work is sent at 1 a.m. Her complete blood count, complete metabolic panel, lipase, urinalysis, and urine human chorionic gonadotropin are all within normal limits. She is treated with a 1 L normal saline bolus, Zofran 4 mg IV, Pepcid 20 mg IV, and ketorolac 30 mg IV, and her symptoms improve.

In the setting of normal blood work and no clear reason for the vomiting, a bedside ultrasound is performed to evaluate the right upper quadrant. The bedside ultrasound is negative for any acute biliary pathology. The patient at this point has changed into a hospital gown and is noted to have self-mutilation marks on her left forearm in the shape of an “M.” When asked about these marks on her arm, she states that she cut herself while cooking. It becomes obvious that there is more to the story. The family and neighbor are asked to step out of the room, and CyraCom translation service is brought to the bedside. The patient is not very cooperative with questioning, but when asked if she took any medications, she admits to taking 27 650 mg Tylenol tablets at 2:30 p.m., about 10 hours prior to arrival. She states she took the pills because she was feeling sad because her boyfriend, whose name begins with “M,” broke up with her.