Please provide a concise presentation script for my attending about a patient with severe epigastric pain radiating to the back (8/10), worsening with meals, present for 2‑3 days, associated nausea and vomiting for 3‑4 days, past appendectomy, currently on unspecified pain medications, and no significant social history.

Patient Presentation Script for Attending

"This is a patient with severe epigastric pain radiating to the back, worsening with meals, concerning for acute pancreatitis or choledocholithiasis, requiring urgent laboratory workup and imaging."

Chief Complaint & History of Present Illness

• Patient presents with severe epigastric pain, 8/10 intensity, radiating to the back for 2-3 days 1, 2
• Pain is constant and worsens with meals 1
• Associated with nausea and vomiting for 3-4 days 1
• The combination of epigastric pain radiating to the back with postprandial worsening and vomiting is characteristic of either pancreatitis or biliary obstruction 1, 2

Past Medical & Surgical History

• Previous appendectomy several years ago
• No other significant surgical history
• Currently taking unspecified pain medications

Social History

• No significant social history reported

Differential Diagnosis Priority

Based on the clinical presentation, the top differential diagnoses requiring immediate evaluation are:

1. Acute pancreatitis - epigastric pain radiating to back is a cardinal feature 2, 3
2. Choledocholithiasis - presents with constant epigastric pain radiating to back (59.6% of cases), associated with nausea (69.2%) and vomiting (30.7%), with pain episodes lasting hours to days 1
3. Peptic ulcer disease - though gastric ulcer pain typically occurs immediately after eating and can radiate to back 2
4. Acute aortic syndrome or cardiac ischemia - must be excluded given severity and radiation pattern 4, 3

Immediate Workup Needed

Laboratory studies:

• Complete metabolic panel with liver function tests (transaminase elevation is the most common abnormality in choledocholithiasis) 1
• Lipase and amylase for pancreatitis evaluation 3
• Complete blood count
• Troponin to exclude cardiac etiology 3

Imaging:

• The ACR Appropriateness Criteria indicate that pain radiating to the back with these symptoms warrants evaluation per acute pancreatitis protocols rather than standard GERD/gastritis workup 4
• Initial imaging should be abdominal ultrasound to evaluate for biliary dilatation (most common imaging finding in choledocholithiasis) and gallstones 1
• CT abdomen with contrast if pancreatitis is suspected based on lipase elevation 3

Critical Pitfalls to Avoid

• Do not dismiss this as simple gastritis or GERD - the radiation to back, severity, and postprandial worsening pattern suggests more serious pathology 4, 2
• Cardiac causes must be excluded first given the severity and radiation pattern, despite the gastrointestinal symptoms 4, 3
• The patient's use of pain medications needs clarification as this could mask progression or contribute to complications 3