Transcript Acute Pancreatitis

Acute Pancreatitis
Celine Estrada
Patient Case
Patient’s Chief Complaint:
“It feels like I have a knife in my
stomach”
History of Present Illness (HPI):
▵ Patient is a 63-year old African
American male, who presents to the
emergency room at the hospital with
intense left upper quadrant pain radiating
to his back and under his left shoulder
blade. He states that he has had
intermittent, upper abdominal pain for
approximately three weeks but that the
pain has been increasing in severity during
the last four days.
History
Patient Medical History (PMH):
▵ Coronary Artery Disease (CAD);
S/P angioplasty 1 year ago; denies any
chest pain since.
▵ Hypertension (HTN); does not remember
exactly how long; he states “for years”
▵ S/P cholescystectomy
▵ S/P appendicitis
▵ (+) for hepatitis C x 5 years
▵ Generalized anxiety disorder; 18 months
Familial History (FH):
▵ Father was an alcoholic and died at
the age of 49 from myocardial
infarction (MI)
▵ Mother alive at 83 with CAD
▵ Brother, age 60, alive and healthy
▵ No family history of gastrointestinal
disease reported
SH & Meds
Social History (SH):
▵ Married with 8 children
▵ Retired high school math teacher
and wrestling coach
▵ Alcohol abuse with 10-12 cans of
beer per day for 15 years
▵ Denies use of tobacco or illicit drugs
Medications (Meds):
▵ Nifedipine 90mg po QD
▵ Lisinopril 20mg po QD
▵ Paroxetine 20mg po QD
▵ Tylenol #3, 2 tablets po QD PRN for
back pain that started recently
Q1. For which condition is this patient likely taking nifedipine?
Q2. For which condition is this patient likely taking lisinopril?
Q3. For which condition is this patient likely taking paroxetine?
Allergies + ROS
Allergies:
▵ PCN  Rash
▵ Aspirin  Hives and wheezing
▵ Cats  Wheezing
Review of Systems (ROS):
▵ States that he’s been feeling “very warm”
and has experienced several episodes of
nausea and vomiting during the past 72
hours
▵ Also describes an 8- to -10 lb weight loss
over the past 1 ½ months secondary to
intense post-prandial pain and loss of
appetite
▵ Reduction of frequency in bowel
movements
▵ No complains of diarrhea or blood in
stool
▵ No knowledge of any previous history of
poor blood sugar control
Physical Examination
Gen:
▵ The patient is a black male who
looks his stated age. He seems
restless and in acute distress. He is
sweating profusely and seems ill. He
is bent forward on the examiner’s
table.
Vitals:
BP
85/60
HR
120
T
RR
35
101.4ºF
WT
154lb
HT
5’7 ½”
Physical Examination (cont.)
Head, Eyes, Ears, Nose, Throat
(HEENT):
▵ PERRLA
▵ EOMI
▵ (-) jaundice in sclera
▵ TMs intact
▵ Oropharynx pink and clear
▵ Oral mucosa dry
Skin:
▵ Dry with poor skin turgor
▵ Some tenting of skin noted
▵ No lesions noted
▵ (-) Grey Turner sign
▵ (-) Cullen sign
Q4. What is meant by “tenting of the
skin” and what does this clinical sign
suggest?:
Q5. Are the negative Grey Turner and
Cullen signs evidence of a good or
poor prognosis?:
Grey-Turner’s Sign
Physical Examination (cont.)
Neck:
▵ Supple
▵ (-) Carotid bruits,
lymphadenopathy, thyromegaly,
and JVD
Heart:
▵ Sinus tachycardia
▵ Normal S1 and S2 and (-) for
additional cardiac sounds
▵ No m/r/g
Lungs:
▵ Clear to auscultation bilaterally
Physical Examination (cont.)
Abdomen (Abd):
▵ Moderately distended with
diminished bowl sounds
▵ (+) Guarding
▵ Pain is elicited with light palpitation
of left upper and mid-epigastric
regions
▵ (-) Rebound tenderness, masses,
HSM, and bruits
Extremities (Ext):
▵ No CCE
▵ Cool and pale
▵ Slightly diminished pulses in all
extremities
▵ Normal ROM throughout
▵ Diaphoretic
Physical Examination (cont.)
Rectum (Rect):
▵ Normal sphincter tone
▵ No bright red blood visible
▵ Stool is guaiac-negative
▵ (-) Hemorrhoids
▵ Prostate WNL with no nodules
Neuro:
▵ A & O x 3 (person, place, time)
▵ Able to follow commands
▵ CNs II-XII intact
▵ Motor, sensory, cerebellar, and gait
WNL
▵ Strength is 5/5 in all extremities
▵ DTRs 2+ throughout
Laboratory Blood Test Results
Na
134 meq/L
Neutrophils
73%
T bilirubin
0.9mg/dL
K
3.5 meq/L
Bands
3%
Alb
Cl
99 meq/L
Eosinophils
1%
Amylase
1874 IU/L
HCO3
25 meq/L
Basophils
1%
Lipase
2119 IU/L
BUN
34 mg/L
20%
Ca
8.3mg/dL
2%
Mg
1.7mg/dL
Lymphocytes
3.3 g/dL
Cr
1.5 mg/dL
Monocytes
Glu, fasting
415mg/dL
AST
291 IU/L
PO4
2.4mg/dL
Hb
18.3 g/dL
ALT
161 IU/L
Trig
971 mg/dL
Hct
53%
Alk phos
266 IU/L
Repeat Trig
969 mg/dL
LDH
411 IU/L
SaO2
WBC
16,400/mm3
96%
Urinalysis
Appearance yellow, clear
SG
1.023
pH
6.5
Glucose
+
Bilirubin
-
Bacteria
-
Ketones
-
Nitrite
-
Urobilinogen
-
Hemoglobin
-
Crystals
-
WBC
2/HPF
Protein
-
Casts
-
RBC
1/HPF
Physical Examination (cont.)
Chest X-Ray:
▵ Anteroposterior view shows heart to
be normal in size
▵ Lungs are clear without infiltrates,
masses, effusions, or atelectasis
Abdominal Ultrasound:
▵ Non-specific gas pattern
▵ No regions of dilated bowl
Abdominal CECT:
▵ Grade C
Q6. Identify three major risk factors
for acute pancreatitis in this patient
Q7. Identify two abnormal laboratory
tests that suggest that acute renal
failure has developed in this patient
Q8. Why are hemoglobin and
hematocrit abnormal?
Q9. How many Ranson criteria does
this patient have and what is the
probability that the patient will die
from this attack of acute pancreatitis?
Q10. Does the patient have a
significant electrolyte imbalance?
Q11. Why was no blood drawn for an
ABG (arterial blood gas)
determination?