Present History
40 year old male Upper abdominal/lower chest pain
Onset 4 hours after eating porketta sandwich
Pressure-like pain Nauseated No fever/chills No prior hx of abdominal or chest pain No exertional pain
Past Medical History
Appendectomy (age 12) Inguinal hernia repair (age 22) Smoking: 20 pack years Alcohol: 3 beers/week Family Hx
Father died of MI (age 42) Brother had coronary angioplasty (age 44) No cancer, HTN, diabetes or CVAs
Past Medical History, continued Social History
Married 2 children Lives in Duluth
Occupational History Golf course superintendent
Mowing, fertilizing and supervising golf course upkeep
Review of Systems – Pertinent Positives
Decreased exercise tolerance SOB after walking 2 blocks
Leg cramps when walking Relieved with rest
Physical Exam
Vital BP: 170/110 HR: 86 RR: 14 Temp: 37.2° C
HEENT White yellow scales around orbits but not
involving the eyes
Physical Exam, continued
Neck Faint left carotid bruit
Heart Pedal pulses are faint bilaterally
Abdomen RUQ tenderness with rebound and guarding Right mid-abdominal bruit Bilateral femoral bruits
G-U: Stool hem negative
Differential: MI
Upper abdominal/lower chest pressure-like pain
20 pack year history of smoking Family History
Father: died of MI at age 42 Brother: coronary angioplasty at age 44
Decreased exercise tolerance/SOB Leg cramps when walking, relieved by rest
Claudication/peripheral artery disease Abundant bruits
Differential: AAA
Abrupt onset of upper abdominal/lower chest pain
Smoking: 20 pack year history Family history of vascular disease Claudication
Differential: Hepatitis
Upper abdominal pain Tenderness to light palpation in RUQ with
rebound and some guarding Nausea
Ruling Out Hepatitis
Liver Panel AST 50 (normal: 10-40 IU/dl) ALT 14 (normal: 5-40 IU/dl) Alk. Phos 72 (normal: 25-125
mg/dl) GGT 18 (normal: 0-51 U/L) Total Bilirubin 0.14 (normal: 0.1-1.2
mg/dl) Hepatitis Serology
negative
Differential: Ischemic Colitis
Peripheral vascular disease Smoking: 20 pack year history Presents as diffuse abdominal pain
Upper abdominal/lower chest pain
Differential: Acute Cholecystitis Upper abdominal/lower chest pain
following a fatty porketta sandwich RUQ pain with rebound tenderness
Nausea Sedentary lifestyle
Ruling Out Acute Cholecystitis Liver Panel
AST 50 (normal: 10-40 IU/dl) ALT 14 (normal: 5-40 IU/dl) Alk. Phos 72 (normal: 25-125
mg/dl) GGT 18 (normal: 0-51 U/L) Total Bilirubin 0.14 (normal: 0.1-1.2
mg/dl) Abdominal Ultrasound
negative
Differential: Acute Pancreatitis Upper abdominal/lower chest pain
RUQ with rebound pain and some guarding
Ruling IN Pancreatitis
Liver Panel AST 50 (normal: 10-40 IU/dl) - H Amylase 520 (normal: 25-125 U/L) – H Calcium 7.8 (normal: 8.4-10.2 mg/dl) – L Glucose 220 (normal: <200mg/dl) - H
Lipid Panel Total Cholesterol 220 (normal: <200 mg/dl) - H Triglycerides 1250 (normal: <150 mg/dl) - H
Lipase Test 630 (normal: 0-160 U/L) - H
Causes of Pancreatitis
EtOH Causes an increase in ductule permeability
allowing the enzymes to reach the parenchyma Causes an intracellular accumulation of
pancreatic digestive enzymes and early release/activation
Causes formation of protein plugs which block outflow due to Increase protein content in pancreatic juice Decrease bicarbonate levels Decrease trypsin inhibitor concentrations
Causes of Pancreatitis, continued Cholelithiasis
Stone in the pancreatic duct or ampulla of Vater leading to obstruction and enzymatic release
Elevated Triglycerides Serum levels over 1000 mg/dl are typically
required to cause acute pancreatitis Familial Hyperlipidemia
Xanthomas on the extensor tendons of the hands, around the eye, on the Achilles tendons and at insertion of the patella tendon
Treatment of Acute Pancreatitis General
Aggressive fluid resuscitation Oxygen supplementation Pain relief with IV morphine or fentanyl Multidisciplinary team involvement
Nutrition Parenteral administration to avoid stimulation of
the pancreas More recently, enteral nutrition has shown to
prevent intestinal atrophy Prevention of Pancreatic Infection
Usually occurs 10 days or more after onset of AP
Ranson’s Criteria
At Admit Age> 55 yr WBC > 16,000 mm³ Glucose > 200 mg/dl LDH > 350 IU/L AST > 250 IU/L
Predicts mortality after 48 hours Each positive finding from above is worth 1 point
<2 points: mortality <1% 3-4 points: mortality = 16% 5-6 points: mortality = 40% 7-8 points: mortality ~ 100%
After 48 Hours Hct drops > 10% BUN increases > 5
mg/dl PO2 < 60 mmHg Base deficit > 4
mEq/L Fluid deficit > 6 L
How much did we spend?
Cardiac Enzymes - $88
CBC - $41 Lipids - $82 Liver Panel - $98 CRP - $73 Abdominal CT -
$618
ECG - $78 Hepatitis Ab –
free!! Lipase - $58 Abdominal
Ultrasound - $370 Abdominal Xray -
$115
$1621 – yikes!
Questions
What is the best way to rule out cholecystitis? A) Lab B) Intuition C) Abdominal Ultrasound D) Have patient eat porketta sandwich.
Questions
Which of the following is NOT common causes of acute pancreatitis? A) Elevated Triglycerides B) Alcohol C) Cholelithiasis D) Eating Porketta Sandwich
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