Approach to vomiting (acute) Quiz: Ace Your Exams

A 46-year-old man presents to the emergency department for evaluation of multiple episodes of non-bloody vomiting and severe upper abdominal pain that began earlier in the day. He describes the pain as constant. It is localized to the epigastric region and radiates to the back. He has not had diarrhea, chest pain, or changes in bowel habits. He has no history of similar symptoms, there is no history of recent trauma, and he does not take any regular medications. Temperature is 37.5°C (99.5°F), blood pressure is 105/70 mmHg, heart rate is 110 beats per minute, respiratory rate is 22 breaths per minute, and oxygen saturation is 98% on room air. Physical examination reveals tenderness to palpation in the epigastrium without rebound or guarding. Bowel sounds are decreased. Laboratory results are shown below. Considering the most likely diagnosis, which of the following historical features is most likely to be present?

Laboratory Test	Result	Reference Range
White blood cell count	14,000/mm³	4,500-11,000/mm³
Serum amylase	460 U/L	25-125 U/L
Serum lipase	720 U/L	0-160 U/L
ALT	35 U/L	8-40 U/L
AST	30 U/L	8-40 U/L
ALP	90 U/L	90 U/L
Total bilirubin	0.8 mg/dL	0.1-1 mg/dL