Transcript Current Case Review

2/27/06 Case
Chief Complaint
• Pt is a 78 y/o caucasion male who
presents w mid-epigastric pain for the
past two months
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patient?
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CC
HPI
PMHx
History of Present Illness
MEDS
Allergies
SocHx
Pt is a 78 y/o c male w/ a hx of CAD, high
cholesterol, smoking hx and etoh history who
FMHx
presents with mid epigastric pain that started two
ROS
months ago and became worse today. Pt has had
Physical Exam a CVI and is a poor historian so additional
information was obtained from his son. The patient
Differential
would complain to the son that his back hurt. The
patient began vomitting today and it contained
LABS
contents from his breakfast. During his episodes of
Radiological
pain the patient denies chest pain, sob,
diaphoresis, frequency, dysuria, fatty food
Diagnosis
dyscrasias or blood in his stool. He did have a
Treatment
decreased appetite today and was unable to be
comfortable.
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Physical Exam
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Radiological
Diagnosis
Treatment
Past Medical History
Hypothyroid
CAD
HTN
CVI
Hypercholesterol
Dementia
Surgeries: Back, CABG
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Physical Exam
Differential
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Radiological
Diagnosis
Treatment
Medications
Lipitor
Plavix 75
Synthroid 25mcg
Toprol 50mg bid
Aricept
Lisinopril 10mg
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Treatment
Allergies
Iodine - anaphylaxis
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Social History
2-3 packs per day for past 58 years
1 shot of liquor a night
Lives at home with son
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Treatment
Family Medical History
MotherFather- Dad died at 48 of MI
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Treatment
Review of systems
General:
Head:
Respiratory:
Cardiac:
GI:
GU:
MSK:
Neuro:
Psychiatric-
weight change, fever, chills, weak
headache, nasuea, vomitting
SOB, wheeze, no cough or URI
HTN, murmurs, hx angina, palpitations
appetite, n/v, incont., no const/diarrhea,
moderate mid epigastric abdomen pain
frequency, hesitancy, urgency, dysuria
hematuria, incont., stones,
muscle weakness, flank pain, muscle
cramps
parasthesias, loss of sensation
Pt has baseline dementia
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• Diagnosis
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Physical Exam
VSBP- 172/83 T-96.7 R-19 P-54
General- Pt is well nourished and AxOx3 but poor
historian
Heent- EOMI, PERRLA, no vision changes
CVRRR w/o murmurs or rubs, clicks or gallops
RESP- Clear to auscultation bilaterally, no wheezes,
rales or crackles
Abdomen- Soft, tender across epigastrium worse in
middle, no rebound, guarding, ND, no masses, no
bruits, no flank discoloration
GUNo discharge, bleeding
MSK- No weakness, no gait disturbances
TTA T5-8 on left
EXT- No edema, pulses b/l,
Neuro- No neurodeficits, CN II-XII intact
Skin- No jaundice
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Differential
RUQ pain
Cholelithiasis
Cholangitis – less likely
MQ
Aneurysm
Pancreatitis
Atypical chest pain
Pneumonia
PE
LUQ
Splenic infarct
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What do we want to order?
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Labs
Chemistry 18
Liver enzymes
Lipase
CBC
Cardiac enzymes
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CBC
13.9 g/dl
10.6
139
41.5
Chemistry
137
103
14
155
4.0
27
1.7
Bili 3.13
LDH 397
AST 288
ALT 136
Lipase >1500
COAGS and cardiac enzymes negative
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Chest X-ray
No flattening of diaghram
Subcostal angles clear
No evidence of pneumonia
EKG
NSR
CT of abdomen was done to rule out AAA
US of gall bladder
Thickened wall
CBD enlargement
Gall stones
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Treatment
Diagnosis
1. Pt is a 78 y/o c male w/ mild pancreatitis caused
by gallstones and contributed to via alcohol
Ransons criteria was 3
NPO
Bowel rest
Fluids at 150 cc/ h
ERCP scheduled for AM to remove stones
2. Hypothyroid – synthroid
Repeat TSH – can contribute to elevated
cholesterol
3. HTN – Toprol, Lisinopril, Vasotec for
breakthrough
4. Hypercholesterol – lipitor
5. Dementia - aricept
Pancreatitis
Definition
• Acute inflammation of the pancreas
– Usually associated with upper abdominal pain
and elevated pancreatic enzymes
• Causes
– Most common gallstones and alcohol
– Early onset pancreatitis (<10 years of age)
• Hyperlipidemia, mumps, trauma
Pancreatitis
Symptoms
• At onset
– Acute upper abdominal pain
• Steady
• Location
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Mid-epigastrium
Right upper quadrant
Diffuse
Confined to the left side (infrequent)
• Acute pancreatitis related to alcohol
– Fequently occurs 1-3 days after a binge or cessation of drinking
• Pain
– Can last for days
• Biliary colic may last for only 6-8 hours
– May have band-like radiation to the back
• ½ of patients
– Painless disease is uncommon (5 to 10 percent)
– May be seen in the postoperative setting
Pancreatitis
Symptoms
• Nausea and vomitting
– 90 percent of patients
– May persist for many hours
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Restlessness
Agitation
Relief on bending forward
Shock or coma.
Hemorrhagic complications
– Rare
• Ecchymotic discoloration of the flanks (Grey-Turner's sign)
– Due to retroperitoneal bleeding
• Pancreatic necrosis
• Bleeding into pseudocysts
Pancreatitis
Physical exam
• Systemic features
– Fever
– Tachycardia
– Shock and coma
• Severe cases
• Severity
– Mild disease
• Epigastrium may be minimally tender
– Severe disease
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Abdominal distention
Tenderness
Guarding
Shallow respirations
– Diaphragmatic irritation
– Inflammatory exudate
• Dyspnea may occur
– If there is an associated pleural effusion.
Pancreatitis
Physical exam
• Ecchymotic discoloration
• An epigastric mass
– Flank (Grey-Turner's sign)
– Periumbilical region
(Cullen's sign)
– Occurs in 1 percent of
cases but is not diagnostic
– Reflect intraabdominal
hemorrhage
– Due to pseudocyst
formation
• Poor prognosis
• Jaundice
– Obstruction of the common
bile duct
• Choledocholithiasis
• Edema of the head of the
pancreas
• May become palpable in
the course of the disease
• Other disorders
– Alcoholic pancreatitis
• Hepatomegally
– Hyperlipidemia
• Xanthomas
– Mumps
• Parotid swelling
Pancreatitis
Labs
• Serum amylase
– Most common
– Rises within 6-12 hours
– Rapidly cleared from blood
– Non specific
• Elevated
– Disease of salivary gland
– Bowel infarction
– Renal failure – decreases clearance
Pancreatitis
Labs
• Lipase
– Once hard to obtain
– 85-100% specificity
• More specific than amylase for pancreatitis
– Can be found in multiple disease states
– Some studies say lipase rises earlier and
remains longer so useful in alcoholic
pancreatitis
Pancreatitis
Imaging
• CT scan
– To rule out pseudocyst
Pancreatitis
Treatment
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NPO
Aggressive fluids
ERCP if gallstones involved
Bowel rest
Reintroduction of nutrition after 4-5 days
Pancreatitis
Ranson criteria
Thank you!
• Questions, comments, concerns?