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SUBMITTED TO: Rowena Marie TulangDATE OF SUBMISSION: November 19, 2013
Samares, MD
SUBMITTED BY: Alvin G. Pasuquin
MEDICINE II
Christian Ayrton
Palomar
Adrian Rey Pancho
Nadiza R. Sechico
REPRESENTATIVE CASE
A case of a 44 year old female, married, flight stewardess was admitted for the 2nd time due to abdominal
pain
Chief complaint: abdominal pain
History of Present Illness:
Present condition was noted 4 hrs pta as sudden onset of mild epigastric pain noted after an
alcoholic binge with some friends.
Took 2 tablets of kremil s (aluminum hydroxide) with some relief afforded, 8 hours prior to
admission pain started to become severe radiating to the back associated with two episodes of
vomiting, an hour prior to admission epigastric pain became boring in character, constant,
associated with diaphoresis thus sought this admission.
Past Medical History:
non-asthmatic
non- hypertensive
non-diabetic
2003- admitted at Silliman medical center hospital due to jaundice during 2nd pregnancy uteri:
diagnosed to have fatty liver and gallstones
2005 chong hua hospital EGD OPD erosive gastritis
Smoker 14 pack years, occ. Tanduay drinker 4-5 shots per day stopped 10 years PTA.
Admitting residents impression : Acute Cholecystitis.
REVIEW OF SYSTEMS
PHYSICAL EXAMINATION
General: on severe pain
General: Febrile, apprehensive patient, not in respiratory distress:
Skin: diaphoresis
Vitals signs: BP=80/60 mmhg, HR=121 bpm, RR=16 cpm, temp= 38.6
HEENT: vomiting
C
Skin: cold clammy
HEENT: sunken eyeballs, dry lips and buccal mucosa, sl. Icteric sclerae
Lungs: clear breath sounds, (-) wheeze
CVS: tachcardic, (-) murmur
Abdomen: soft, hypoactive BS, (+) direct tenderness epigastric area,
(-) murphys sign, (+) cullens sign, liver not enlarged
Extremities: (-) edema, faint bipedal pulses
PRIMARY WORKING IMPRESSION
ACUTE GALLSTONE
PANCREATITIS
RULE IN
History:
Age (Hospitalization rates
increases with age. Rate x4 in
female)
Acute onset boring, constant,
severe epigastric pain radiating
to the back; (+) 2 episodes of
vomiting; (+) medical history of
chronic alcoholism, gallstones.
Physical Examination:
(+) febrile, tachycardia,
hypotension, cold, clammy
skin, sunken eyeball, dry lips
and buccal mucosa, hypoactive
RULE OUT
History:
Female gender, age, boring,
constant, severe epigastric
pain radiating to the back; (+)
2 episodes of vomiting; (+)
medical history of chronic
alcoholism, gallstones.
Laboratory Examination
CHRONIC PANCREATITIS
MYOCARDIAL INFARCTION
Amylase,
Ultrasound revealed intense
echoes with sizes ranging from
0.5 -1 cm. Gallbladder wall is
diffusely thickened. The
intrahepatic duct and common
bile duct are dilated. The
pancreas is obscured by
overlying gas.
ERCP showed a filling defect in
the common bile duct near the
insertion of pancreatic duct.
History:
epigastric pain which radiates
to the back, vomiting, smoker
(14 pack years), Tanduay
drinker (4-5 shots a day), pain
relieved by Kremil-S
Physical Examination:
(+) fever, (+) hypotension,
tachycardic, (+) cold, clammy
skin, sunken eyeballs, dry lips
and buccal mucosa, (+)
epigastric tenderness
History:
epigastric pain radiating to the
back, (+) episodes of vomiting,
diaphoresis
Workups to order
Urea breath test
Upper GI endoscopy
PMH: Non-hypertensive
(-) altered mental status, (-)
atypical chest pain, (-)
lightheadedness with or without
Physical Examination:
(+) cold, clammy skin,
tachycardia, (+) hypotension
(in the setting of MI usually
indicates a large infarct
secondary to global cardiac
contractility or a right
ventricular infarct)
faint pedal pulses,
History:
Physical Examination:
History:
severe abdominal pain,
vomiting
ACUTE MESENTERIC VASCULAR
OCCLUSION
ACUTE CHOLECYSTITIS
APPENDICITIS
Physical Examination:
(+) direct tenderness, soft,
hypoactive bowel sounds,
hypotensive
History:
Female gender, Age (increases
rates of gallstones), epigastric
pain lasting for >12 hrs,
jaundice, 2 episodes of
vomiting, alcoholic binge,
previous history of gallstones
Physical Examination:
(+) fever, hypoactive bowel
sounds, sunken eyes, dry lips
and buccal mucosa, slightly
icteric sclera
History:
(+) epigastric pain
Physical Examination:
(+) febrile, tachycardic,
hypotensive,
Laboratory Examination:
WBC
GASTROESOPHAGEAL REFLUX
DISEASE
History:
44 years old (prevalence of
GERD increased in people older
than 40 years), (+) history of
vomiting
Normal
Range
Patient's Result
Interpretation/Necessity
Availability
Cos
t
Hematocrit
RBC
13-18 g/dL
40-52%
4.4-5.9 M/uL
450011,000/uL
WBC
- Segmenters
- Lymphocyte
- Monocyte
- Eosinophil
RED CELL
INDICES
Creatinine
41
4.8
13,300
88
20-35%
4-8%
1-4%
Platelet Count
13.86
150,000400,000/uL
MCV: 80-98 fL
MCH: 26-34 pg
MCHC:32-36
%
SUMC
NOPH
FreeStanding
Labs
250
SUMC
NOPH
FreeStanding
Labs
120
SUMC
NOPH
FreeStanding
Labs
120
SUMC
NOPH
FreeStanding
Labs
170
SUMC
NOPH
FreeStanding
Labs
240
3
1
322,000
85
28.5
37.8
0.73
(ALT)/SGPT
17- 59 IU/L
434
ALP (Alkaline
20 to 140 IU/L
410
250
Phosphatase)
Sodium
Potassium
Urinalysis
135-145
meq/L
3.6-5.0 meq/L
Specific
gravity: 1.0161.022
138.40
3.66
1.020
negative
Blood:
negative
pH= 7.0
pH: 5.5 - 7.5
1+
Protein:
negative
18
RBC: 0-2
cells/hpf
Bacteria: rare
Mucous
threads: few
707
SUMC,
NOPH,HCH
SUMC
NOPH
FreeStanding
Labs
290
ULTRASOUND
OF THE
WHOLE
ABDOMEN
SUMC
NOPH
FreeStanding
Labs
145
0
Unremarkable
Several intense
echoes (at least 8)
with sizes ranging
from 0.8-1cm.
Gallbladder wall is
remarkably
thickened. The
intrahepatic duct
and common bile
duct is dilated. The
pancreas is
obscured by
overlying gas.
Unremarkable
Showed a filling
defect in the
common bile duct
near the insertion
of the pancreatic
duct.
Endoscopic retrograde
cholangiopancreatography
(ERCP) combines endoscopy
and X-ray to treat problems of
the bile and pancreatic ducts.
SUMC
NOPH
FreeStanding
Labs
10,
000
40,
000
OTHERS
ERCP
THERAPEUTICS
Problem List
Therapeutic Objectives
1. Severe epigastric pain
1. To treat the underlying cause of the disease
that radiates to the
2.
To minimize and ease the abdominal pain sensation
back
3.
To manage vomiting, diaphoresis, tachycardia, fever, and the other
2. Vomiting
presenting signs of dehydration.
3. Diaphoresis
4.
To maintain vital signs within normal range with constant
4. Fever = 38.6
monitoring
5. Tachycardia
5.
To be able to closely monitor the intake and output
6. Sunken eyeballs, dry
6. To ascertain primary working impression of Acute Cholecystitis by doing
skin and buccal
further with other diagnostic exams
mucosa
8. To prevent further complications
7. Icteric Sclera
8. (+) direct epigastric
tenderness
9. (+) Cullens sign
MANAGEMENT
Advice and Information
Non-pharmacologic Management
Educate the patient, as well as the family, about
Admit patient to ICU care for further
her medical condition.
work-up
Provide information on the etiology, risk factors,
Monitor vital signs every four hours
course of the disease, signs and symptoms and
Monitor severity of abdominal pain
treatment.
Insert IV line D5 LR @ 55 gtts/min
Encourage increasing fluid intake.
NPO
Ask if she needs any clarification.
On Total Parenteral Nutrition
Emphasize on the importance of compliance of
Strict monitoring of I & O
drug regimen.
O2 therapy @ 2 L/min
Advice and inform the patient on the importance
Maintain Bed Rest without bathroom
of lifestyle modification particularly in observing
privileges
proper diet and exercise.
Perform diversional techniques to provide
Instruct the patient to return for follow up check
pain relief
up after discharge, as advised.
Prepare patient for ERCP
Ensure patient safety
PHARMACOLOGIC MANAGEMENT
Drug Name
Efficacy
Safety
Suitability
Cost
Opiod Analgesics
Meperedine
Narcotic agonistContraindication
Moderate to severe
Amp
(Demerol)
analgesic of opiate
Acute abdominal conditions,
pain
100mg/m
receptors; inhibits
pseudomembranous colitis,
L
ascending
severe respiratory
(P1483.3
pathways, thus
insufficiency, toxin-mediated
2)
altering to response diarrhea
to pain; produces
Caution
analgesia,
Potential for tolerance and
respiratory
drug dependence, narrow
depression, and
therapeutic index, cardiac
sedation
arrhythmias
Antipyretic
Paracetamol
Inhibits
Contraindication
Fever, mild to
Amp
(Naprex)
prostaglandin
Hypersensitivity, severe
moderate pain
300mg/2
synthesis
hepatic impairment
mL
Caution
(P32.05)
High dose may result to
hepatic injury
Antibiotics
Meropenem
Inhibits cell wall
Contraindication
Treatment of infections
Powder
trihydrate
synthesis by
Hypersensitivity
caused by single or
for
(Meronem)
binding to
Caution
multiple susceptible
injection
penicillin-binding
Seizures have been reported, bacteria sensitive to
500mg
proteins; resistant
Clostridium difficilemeropenem.
(P1889.5
to most betalactamases
Pneumonias including
hospital acquiredm,
septicemia,
neutropenia, intraabdominal infections,
meningitis, UTI,
gynecological, skin and
skin structure
infections
0)
1g
(P3157.2
0)
References:
Bickley, A. et. Al. (2009).BatesGuide to Physical Examination and History Taking. 10thed.
Chernecky, C & Berger B., (2008). Laboratory Test and Diagnostic Procedures. 5th ed. Saunders Elseviers: Philadelphia
Fauci, A. et Al. (2012). Harrisons Principles of Internal Medicine. 18th ed. McGraw-Hill
Medical Publishing Division, USA.
MedScape. June 22, 2013. www.medscape.com
PRESCRIPTION:
Alvin G. Pasuquin, MD
Silliman Medical Center
Dumaguete City
(035) 2254535
Patient:
Date:
Address:
Age/Sex:
Alvin G. Pasuquin, MD
Silliman Medical Center
Dumaguete City
(035) 2254535
Patient:
Date:
Address:
Age/Sex:
Alvin G. Pasuquin, MD
Silliman Medical Center
Dumaguete City
(035) 2254535
Patient:
Date:
Address:
Age/Sex:
_______________ MD
_______________ MD
_______________ MD
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