Publication Date: April 2018 (Volume 20, Number 4)
You are in the middle of a busy Monday afternoon shift in the ED. The chief complaint on the track board simply states, “other complaint,” but one look at the patient tells you why he is here. The patient is a middle-aged man with no prior medical history who states that his family has been telling him for the last 2 to 3 weeks that his eyes are yellow. He also admits to occasional nausea, vomiting, poor appetite, weight loss, and diffuse itching. There is no history of fever, abdominal pain, heavy alcohol use, or recent acetaminophen ingestion. Your physical examination is remarkable for icteric sclerae, jaundice of his face and upper chest, and mild, nontender hepatomegaly. You want to order imaging in addition to lab work, but wonder which is the better choice: CT or ultrasound?
A second patient, a young woman, presents via EMS. The EMTs state they were called to the house for altered mental status. There was nobody in the home to provide collateral information, but they did notice numerous empty medication bottles, though they were unsure what kinds of medications they were. The patient is responsive only to painful stimuli. Vital signs are otherwise stable, but you notice scleral icterus, diffuse jaundice, and petechiae on examination. You are obviously concerned about an ingestion, but you wonder whether you should begin N-acetyl-cysteine therapy empirically.