Case number 31
A 44-year-old construction worker comes to the emergency department due to nausea and fatigue over the past 2 days.  The patient strained his back at work 7 days ago.  He was unable to move for several days and has been taking over-the-counter pain medications and applying hot packs.  The patient still has significant back pain and limited mobility.  He smokes 1 pack of cigarettes a day.  The patient drinks alcohol daily and heavily on weekends.  In addition, he uses intravenous heroin on occasion.

He was hospitalized for pneumonia 6 months ago and treated with intravenous antibiotics.  Echocardiogram during that admission showed normal left ventricular systolic function, a mildly dilated right ventricle, and mild pulmonary hypertension.

Temperature is 37.2 C (99 F), blood pressure is 94/50 mm Hg, and pulse is 112/min.  There is mild scleral icterus.  Several needle tracks are seen on both forearms.  No heart murmurs are present.  The lungs are clear.  There is no abdominal distension.  Moderate right upper quadrant tenderness is present.  The spleen is not palpable.  There is no peripheral edema.

Laboratory results are as follows:

Serum chemistry
Sodium 148 mEq/L
Potassium 3.2 mEq/L
Chloride 106 mEq/L
Bicarbonate 22 mEq/L
Blood urea nitrogen 27 mg/dL
Creatinine 1.7 mg/dL
Liver function studies
Albumin 3.8 g/dL
Bilirubin
Total 3.2 mg/dL
Direct 2.2 mg/dL
Alkaline phosphatase 190 U/L
Aspartate aminotransferase (SGOT) 3578 U/L
Alanine aminotransferase (SGPT) 4235 U/L
Coagulation studies
International Normalized Ratio (INR) 1.7