ER CASE REPORT
PATRICK J. NAGLE


A 79 y/o female Caucasian presented to the ED with a
friend complaining of severe, sharp epigastric pain that
radiated into her chest, back, and pelvic region.
She has been having the pain for about 2 months, but it
has progressively been getting worse since that time.
Initially the pain was rated at a 2 or 3 out of 10, but within
the past week has become a constant sharp pain rated
between 8 and 10 out of 10.
 She now has a lot of difficulty eating because the pain is
so severe.


Pt thought she was constipated so she took some overthe-counter Colace thinking it would help. This was
the only method of relief the pt attempted and it was
unsuccessful.

The pt denies having any fever, chills, night sweats,
abnormal weight loss/gain, malaise,
lymphadenopathy, difficulties or painful swallowing,
N/V/D, blood in her mucus or stools, change in color
or caliber of bowel movements, difficulties or changes
in urination, wheezing, cough, SOB, SOB on exertion,
chest tightness or pressure, palpitations, PND,
orthopnea, fainting, dizziness, swelling of feet, or
abnormal bleeding and bruising.




Pt is known to have allergies to iodine resulting in
kidney failure.
PMH revealed documentation of Type II DM, HTN,
hypercholesterolemia, CHF, stroke, MI, CAD, CABG x
3 - 2 months ago, AAA repair - 2 years ago, complete
left mastectomy 7 years ago, GERD, removal of her
gallbladder and appendectomy – over 20 years ago.
Both sides of the patient’s family has a history of DM,
HTN, dyslipidemia, and breast cancer is known on her
side of the family.
She has not been exposed/used tobacco, alcohol, or
illicit drugs.

Pt appears to be in moderate to severe discomfort with
severe, sharp pain throughout the epigastric region of
her stomach that radiated into the chest, back, and
pelvic area.
Abdominal aorta auscultated with no sounds indicating a
possible leak. Normoactive bowel sounds with clicks and
gurgles noted.
 2+ peripheral pulses, radial and dorsalis pedis without
radial/femoral delay were also noted to examine for a
possible leak in the abdominal aorta.
 Pain in the epigastric and pelvic region was increased
upon palpation and no organomegaly was noted.



Lungs clear to auscultation and vesicular breath
sounds were heard at the bases bilaterally with no
crackles, rales, rhonci, rubs, or wheezing. RR at 20.
Heart was a regular rhythm at a rate of 106, PMI was
localized at the left 5th ICS mid-clavicular line. No S3,
S4, murmurs, thrills, or lifts noted.



Scarring was noted on the left side of the chest from prior
CABG and mastectomy.
Rectal exam to determine if there was any blood in the
stool, which the stool guaiac was negative.
The rest of the exam revealed no signs/symptoms of a
disease process.



AMI and a leaking AAA were the most emergent
diagnoses. Bowel obstruction, pancreatitis, GERD,
hiatal hernia, peptic ulcer disease, indigestion,
constipation, and pneumonia were also included.
Extensive labs were conducted because of the
presentation. These included a CBC with diff., CMP,
Amylase/Lipase, Troponin, CPK, U/A, Uroscreen, PT,
PTT, INR, EKG and cardiac monitoring.
Imaging studies that were completed consisted of a
CXR, Abdominal Flat & Upright X-ray and MRI of the
abdomen.






EKG was immediately done - nonspecific T wave
abnormality previously seen on the EKG.
Troponin - 0.0, within normal limits (0.0 – 0.3).
MRI and Abdominal Flat & Upright X-rays reviewed
by the ER doctor to examine for any signs of a leaking
AAA, bowel obstruction, pancreatitis, PUD, and
constipation - No acute processes noted.
CXR to r/o pneumonia - Negative.
Amylase of 56 (range of 22-125 IU/L), lipase of 26
(range of 22-51 U/L) supported no acute pancreatitis.
PT, PTT, and INR were within the accepted range.




Lab results from the CBC with diff and CMP were in
the accepted range for this institution, except for the
alkaline phosphatase .
Alkaline phosphatase - 548 (range of 42-121 IU/LA).
Review of previous lab studies conducted on the
patient since January of 2008 showed a slow and
gradual elevation of the alkaline phosphatase.
Radiologists interpretation of MRI - lytic lesions, often
seen with bone metastasis from breast cancer. Lesions
were imaged on the patient’s ribs, T&L spine, and
pelvis.

KEY HISTORY – PATIENT HAD A COMPLETE LEFT
MASTECTOMY WITHOUT LYMPH NODE INVOLVEMENT 7
YEARS AGO.

Therapeutic options for a progressed stage of cancer
like this are only palliative in nature.

Radiation or chemotherapy.



Always consider the possibility of a relapse of cancer.
Zebras are not common, but you must remain openminded to the possibility that you may see one.
For this patient, catching the gradual increase of
alkaline phosphatase and conducting the proper
imaging studies could have lead to a different outcome
and not a terminal illness.




ALP. (2007, July 30). Retrieved July 8, 2009, from Lab
Tests Online:
http://www.labtestsonline.org/understanding/analytes
/alp/test.html
Degroot III, H. (2009). Bone Metastasis. Retrieved July 13,
2009, from Bonetumor.org:
http://www.bonetumor.org/tumors/pages/page67.htm
l
Metastatic Bone Cancer. (2007, October). Retrieved July 8,
2009, from American Academy of Orthopaedic Surgeons:
http://www.orthoinfo.aaos.org/topic.cfm?topic=A00093
What is Bone Cancer? (2009, May 13). Retrieved July 13,
2009, from American Cancer Society:
http://www.cancer.org/docroot/CRI/content/CRI_2_4_
1X_What_Is_bone_cancer_2.asp