CC: 42 y/o Caucasian female presents to the ED with abdominal pain.
History:
Onset: Sudden onset today.
Location: Patient points to epigastric region
Duration: Constant
Characterization: Sharp
Alleviating/aggravating: Pain is worse with lying in the supine position.
Radiation: radiating to the back and right upper quadrant
Timing: No specific time makes it better or worse.
Severity: 7/10
Associated symptoms: Nausea, vomiting, fever, the rest of ROS are negative.
Diet: Consumed french toast for breakfast, pain started shortly after.
Past Medical History: None
Past Surgical History: None
Social History: Denies drinking, smoking or illicit drug use
Sexual History: Sexually active with one male partner, uses condoms for protection
Family History: Non-contributory
Vitals:
BP: 130/85 left arm seated
HR: 80 beats per minute (regular)
O2 sat: 98% on room air
RR: 18 beats per minute, unlabored
Height: 5 ft 6 inches
Weight: 185 lbs
BMI: 29.9
Physical Exam:
General: Obese female who appears her stated age of 42. Alert and oriented to person, place and time. Patient appears in mild distress.
Skin: Good turgor
Eyes: Sclera icteric, PERRL
Mouth: Mucous membranes appear moist
Lungs: Clear to auscultation in all lung fields. No adventitious breath sounds.
Heart: Regular rate and rhythm. S1 and S2 present. No murmurs, or gallops.
Abdomen: Non-distended, no ecchymosis, scars, striae. Bowel sounds present in all four quadrants. Epigastric tenderness to palpation. Guarding present. No rebound tenderness.
Differential Diagnosis:
Pancreatitis – commonly presents with severe epigastric pain radiating to the back
Choledocholithiasis – Pain radiates to RUQ + jaundice, patient has multiple risk factors, she is fat, fertile, female, fair skin and 42.
Cholangitis – Pain radiates to RUQ + jaundice
Cholecystitis – RUQ pain
Hepatitis –Pain radiates to RUQ + jaundice
Tests:
CBC: WBC count 15,000 /microliter
CMP: Glucose of 180 mg/dL, ALT 175 U/L (normal 7-55 U/L), AST 115 (normal 5-40), Alkaline phosphatase (normal 20 – 140 IU/L), Total bilirubin 3.1 mg/dL (normal 0.3 – 1.2 mg/dL)
Lipase: 500 U/L (normal value 10 – 140 U/L)
Coags: in case the patient needs surgery
Abdominal CT: shows pancreatic parenchymal enlargement suggestive of pancreatitis.
Abdominal Ultrasound: dilated common bile duct, multiple stones noted in the gallbladder
Diagnosis: This patient has acute pancreatitis secondary to gallstones.
Management:
Admit patient for monitoring, NPO, IV fluids, measure urine output, pain control with meperidine.
Patient Counseling:
I will explain to the patient what pancreatitis is. I will use a visual.
The pancreas makes hormones and juices to help digest food. The juices come through a duct called the pancreatic duct. Your duct is blocked due to a gallstone. The liver makes bile which is stored in the gallbladder. Sometimes this bile hardens and forms stones. Sometimes these stones are harmless and we don’t notice them, but in your case the stone traveled and blocked the pancreatic duct. The juices from the pancreas have no where to go, they stay in your pancreas and damage the pancreas, which causes you pain. Pancreatitis usually settles down after a few days, but in your case it is important to address the cause, which is the stone. Your stone is an obstructive stone and will require Endoscopic retrograde cholangiopancreatography (ERCP). The ERCP involves a flexible tube going down your throat into the digestive tract. Contrast dye and x-rays will be used to help visualize the stones. The doctor will widen the bile duct and the obstructing stones will be removed. The doctor may place a stent in to keep the bile duct open. You will be staying in the hospital to be monitored and for IV hydration. Nothing by mouth until the pancreas settles down a little bit. You will slowly go back to a regular oral diet.
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