A 87 year old female NH resident with a history of chronic atrial fibrillation, hypertension and hypothyroidism who presents wit abdominal pain.  She had been in her usual state of health until 5 days ago when she suddenly began to have abdominal pain.  Her abdominal pain was initially intermittent lasting for a few hours at at time.  No clear correlation with food.  Yesterday, she noticed that her pain was much more severe and more localized to the right.  This was accompanied by nausea and vomitting.  She vomitted twice, with clear liquid emesis and was sent to a hospital.  At the hospital, she was noted to have elevated amylase/lipase to 538 and 516 with elevated bili to 4.1 and AST/ALT to 198/115 and was given ciprofloxacin, flagyl and 500cc NS and was transferred to the emergency department.  At the emergency department her vital signs were TM 97.9  HR 83  BP 157/92  RR 18 sat 97% RA.