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Nkem(she, her, hers) is a 48-year-old Somalian woman who presents to the emergency department for nausea and vomiting. Vitals Name: Nkem okaya Sex assigned at birth: Female Gender: Woman Height: 5′ 4″Height: 5 feet 4 inches Weight: 270 pounds Vital signs: Stable Chief Complaint “I’ve been throwing up about 5 minutes after I eat or drink anything for the past 3 days.” HPI Patient reports a 3-day history of vomiting approximately 5 minutes after consuming solids or liquids. She’s had 10 vomiting episodes that were associated with a sensation of “fullness” and complains of an “aching” sensation that she rates 6/10 (0 none, 10 severe) that diffuses over the upper gastric area, and nothing seems to alleviate the feeling. She’s not had a bowel movement in 3 days. She reports having uncontrollable cravings to eat paper products, “Cardboard is just so delicious,” which lead to her consuming large amounts of cardboard and newspaper in the days before she began vomiting. She reports a long history of pica “most of my life” though experienced an uncontrollable exacerbation after gastric bypass surgery 2 years ago. “After my surgery, it was like a roller coaster—I had such intense and chaotic bouts of pica, and eventually I had to go to the hospital and have a gastric bezoar removed.” Aside from cravings to eat cardboard and newspaper, she reports having urges to eat charcoal, moist soil, clay, chalk, pencils, and new shoes, which she chews on. “I first experienced pica when I was 15 years old and was pregnant with my first child. I had severe cravings and urges to eat soil. They went away for a while but came right back when I got pregnant with my second child.” She reports experiencing pica with all 5 pregnancies, and during her last pregnancy 4 years ago, the pica became out of control, leading to her eating 2 to 3 pencils with erasers every day. “After I ate the pencils, it’s like this wave would wash over me, and I felt so much more relaxed.” History Medical history: Obesity Surgical history: Roux-en-Y gastric bypass procedure 2 years ago; laparoscopic gastric bezoar removal and incisional hernia repair 3 years ago Psychiatric history: Anxiety, depression, personality disorder traits of emotional dysregulation, pica, questionable OCD vs GAD; previously took Ativan and Prozac but stopped both during her last pregnancy out of concern they would affect the baby, otherwise denies side effects Family history: Mother—pica Social history: Denies alcohol use, denies illicit substance use, no tobacco use Reproductive: Last menstrual period was 8 days ago Allergies: No known drug allergies Current medications: Ativan (lorazepam) 1 mgMilligram daily ROS Denies shortness of breath or chest pain + Constipation, + upper gastric aching 6/10 (0: none, 10: severe), + uncontrollable cravings to eat paper products, specifically cardboard Physical Exam Mild abdominal distention, no guarding, no tenderness, no rigidity or palpable masses or rebound tenderness Tests CT of abdomen: Post-surgical changes involving small bowel consistent with gastric bypass surgery and hiatal hernia repair, otherwise no obstruction, no focal inflammation, no free fluids or gas Labs: Amylase, lipase, UA, coagulation studies, cardiac enzymes, CMP, and CBC: all within normal limits Ferritin: 10 ng/mL Nanograms per milliliter(range: 10 to 120 ng/mL Nanograms per milliliter) Vitamin B12: 299 pg/mL Picograms per milliliter(range: 100 to 700 pg/mL Picograms per milliliter) Iron: 25 mcg/dLMicrograms per deciliter (range: 50 to 170 mcg/dLMicrograms per deciliter) Endoscopic foreign body removal from stomach: Pathology results reveal it to be a gastric bezoar, yellow-green color, 2.5 cm × 1 cm × 0.8 cm in size. What may be causing Nkem’s pica symptoms?
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