A 65-year-old woman comes to the emergency department due to 2 days of nausea and vomiting. Her symptoms started a few hours after eating lunch, and she has since been unable to tolerate any oral intake. The patient began to experience epigastric and retrosternal discomfort this morning, and she now has pain in all her joints and muscles. Medical history includes hypertension; type 1 diabetes mellitus; myocardial infarction 2 years ago that was treated with coronary stenting; and severe, degenerative lumbar spinal stenosis. Medications include aspirin, atorvastatin, insulin, lisinopril, metoprolol, and morphine.
Temperature is 36.7 C (98 F), blood pressure is 150/90 mm Hg, pulse is 94/min, and respirations are 18/min. The patient is awake and oriented to time, place, and person. Physical examination is significant for diaphoresis and rhinorrhea. Abdominal examination is significant for epigastric tenderness and hyperactive bowel sounds. ECG shows nonspecific ST-T changes. An older ECG is not available for comparison.
Which of the following is the most likely cause of this patient's clinical presentation?

Question

A 65-year-old woman comes to the emergency department due to 2 days of nausea and vomiting.  Her symptoms started a few hours after eating lunch, and she has since been unable to tolerate any oral intake.  The patient began to experience epigastric and retrosternal discomfort this morning, and she now has pain in all her joints and muscles.  Medical history includes hypertension; type 1 diabetes mellitus; myocardial infarction 2 years ago that was treated with coronary stenting; and severe, degenerative lumbar spinal stenosis.  Medications include aspirin, atorvastatin, insulin, lisinopril, metoprolol, and morphine.
Temperature is 36.7 C (98 F), blood pressure is 150/90 mm Hg, pulse is 94/min, and respirations are 18/min.  The patient is awake and oriented to time, place, and person.  Physical examination is significant for diaphoresis and rhinorrhea.  Abdominal examination is significant for epigastric tenderness and hyperactive bowel sounds.  ECG shows nonspecific ST-T changes.  An older ECG is not available for comparison.
Which of the following is the most likely cause of this patient's clinical presentation?

Quizplus · Accepted Answer

11ec193a_9688_d50d_853d_bdb9ed1d79c2_MD0002_00 This patient likely contracted a foodborne illness after eating lunch. The resultant nausea and vomiting left her unable to tolerate oral intake, causing abrupt cessation of her oral morphine. The development of abdominal cramping, arthralgias, myalgias, diaphoresis, and rhinorrhea 2 days later (when symptoms of acute gastroenteritis should be diminishing) is most likely due to opioid withdrawal. Tolerance to opioids, a prerequisite for withdrawal, generally develops after ≥3 weeks of regular use. Opioid withdrawal typically begins within 3 half-lives of abrupt discontinuation (ie, within 6-12 hours in the case of short-acting morphine; 24-48 hours for long-acting) in patients with prolonged use. Symptoms typically peak within 3 days of last use and may persist for up to 10 days. (Choice A) Although acute pancreatitis may present with nausea, vomiting, and mid-epigastric abdominal pain that radiates to the back, it is rarely associated with diffuse joint and muscle pain. Given the abrupt cessation of morphine, opioid withdrawal better explains the patient's condition. (Choice B) Hypoglycemia may be associated with palpitations, diaphoresis, and anxiety. Hypoglycemia would not explain this patient's presentation. (Choice C) Non-ST-elevation myocardial infarction (MI) can present with chest pain, gastrointestinal symptoms (eg, abdominal pain, nausea, vomiting), and diaphoresis. Although this patient has a history of recent MI and may warrant further evaluation (eg, serial troponins), her overall clinical picture and history of opioid use are more consistent with opioid withdrawal. (Choice E) The rapid onset of gastrointestinal symptoms after eating lunch (ie, <6 hours) points to a foodborne, preformed toxin as the cause of this patient's gastroenteritis. However, foodborne illness caused by a preformed toxin rarely persists for >2-3 days, typically peaks in severity within this timeframe, and is rarely associated with diffuse joint and muscle pain. Educational objective: Symptoms of opioid withdrawal generally begin within 1-2 days after abrupt opioid cessation in patients with sustained use (ie, ≥3 weeks). Clinical features include gastrointestinal symptoms (eg, persistent nausea/vomiting), rhinorrhea or lacrimation, diaphoresis, arthralgias, myalgias, mydriasis, and cardiac symptoms (eg, tachycardia). __________ References: Opioid withdrawal syndrome: emerging concepts and novel therapeutic targets. (http://www.ncbi.nlm.nih.gov/pubmed/23244430) Tapering long-term opioid therapy in chronic noncancer pain: Evidence and recommendations for everyday practice. (http://www.ncbi.nlm.nih.gov/pubmed/26046416)

A 65-Year-Old Woman Comes to the Emergency Department Due to 2