Triage: BIBM from home for weakness, not eating x4 days, +N/V. Ambulates with walker baseline. PMH dementia A&Ox2, neuropathy, tremors

History of Present Illness: female with a history of neuropathy who presents with nausea, vomiting, inability to tolerate oral intake for 4 days, and several episodes of diarrhea. She denies abdominal pain, chest pain, and shortness of breath. The patient has not been able to tolerate anything by mouth for the past four days.

Vital Signs: T: 36.5 °C (Oral) HR: 77 (Peripheral) RR: 18 BP: 147/97 SpO2: 96%

Physical Exam: Oriented x 2, otherwise normal

Initial Diagnostic Testing:

  • CBC & UA: normal
  • Chem7: bicarbonate of 15. Anion gap 20
  • LFTs: AST 1088, ALT 2029, Alk Phos 185. bilirubin 2.0.
  • US: stones w/o cholecystitis, distended CBD, no choledocholithiasis, mild hepatomegaly.

What if any additional workup should you consider?

  • A) Tylenol level
  • B) Hepatitis panel
  • C) CK level
  • D) A and B

 

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What if any additional workup should you consider?

  • A) Tylenol level
  • B) Hepatitis panel
  • C) CK level – This should be checked whenever AST >4x ALT
  • D) A and B – CORRECT

 

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CASE CONCLUSION:

  • Tylenol level elevated at 67.
  • Poison control consulted
  • Initiated on N-acetylcysteine for elevated Tylenol level.
  • Repeat Tylenol level and LFTs improving
  • Family states pt using tylenol for HA in past week or so.
  • CT head and carbon monoxide normal.
  • Likely Tylenol wasn’t helping headache much and was left out so she kept taking it not remembering when she last took it because of her dementia

CASE LESSONS: