Gastro Case Challenge: A Daily Cannabis User With Sharp, Intense Epigastric Pain

Saad A. Shebrain, MD; Hailey Chang, MD


July 11, 2022

Physical Examination and Workup

Upon physical examination, the patient is well-developed, malnourished, and in mild distress. His temperature is 98.1°F (36.7°C), his heart rate is 75 beats/min, his respiratory rate is 20 breaths/min, and his blood pressure is 117/63 mm Hg. His height is 5'7" (1.7 m), his body weight is 135 lb (61.2 kg), and his body mass index is 21.1 kg/m2.

The patient's head is normocephalic and atraumatic, his extraocular movements are intact, and no scleral icterus is observed. His mucous membranes are slightly dry, and his neck is supple, with normal range of motion. Auscultation of the lungs reveal equal and symmetrical breath sounds that are clear bilaterally, with no increased work of breathing.

Cardiovascular examination reveals a regular rate and rhythm with normal heart sounds, absence of murmurs, and intact distal pulses. Abdominal examination reveals a soft, scaphoid, nondistended abdomen, with no tenderness to palpation and normal bowel sounds. Musculoskeletal survey reveals normal range of motion, and skin examination reveals skin that is warm, relatively well-perfused, and without any lesions. Neuropsychiatric examination reveals normal mood and affect, and the patient is neurologically intact.

The patient is admitted to the hospital and started on fluid resuscitation and given multiple doses of ondansetron and morphine for nausea and pain control. His symptoms persist, so promethazine is given, with minimal relief. A work-up is initiated. Basic laboratory test results, including complete metabolic profiles and complete blood count, are within normal limits.

CT of the abdomen and pelvis are obtained to evaluate the abdominal pain (Figure 1). Upper gastrointestinal endoscopy is also performed (Figures 2 and 3).

Figure 1.

Figure 2.

Figure 3.


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