1 “It feels like I have a knife in my stomach” Patient CasePatient’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.
2 History Patient Medical History (PMH): Familial History (FH): ▵ 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 monthsFamilial 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 reportedS/P: status/post
4 SH & Meds Social History (SH): ▵ Married with 8 children ▵ Retired high school math teacher and wrestling coach▵ Alcohol abuse with cans of beer per day for 15 years▵ Denies use of tobacco or illicit drugsMedications (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 recentlypo: per os – by mouthQD: quaque die – every dayPRN: as needed (pro re nata)S/P: Status/Post
5 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?
6 Allergies + ROS Allergies: ▵ PCN Rash ▵ Aspirin Hives and wheezing ▵ Cats WheezingReview 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 controlPCN: Penicillin
7 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 /60T ºFWT lbHRRRHT 5’7 ½”Low BP because of HTN meds? Fast HR Fever
8 Physical Examination (cont.) Head, Eyes, Ears, Nose, Throat (HEENT):▵ PERRLA▵ EOMI▵ (-) jaundice in sclera▵ TMs intact▵ Oropharynx pink and clear▵ Oral mucosa drySkin:▵ Dry with poor skin turgor▵ Some tenting of skin noted▵ No lesions noted▵ (-) Grey Turner sign▵ (-) Cullen signPERRLA: Pupils equal, round, reactive to light and accomdationEOMI: Extra-ocular movements intactTM: Tympanic membrane
9 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?:
11 Physical Examination (cont.) Neck:Supple(-) Carotid bruits, lymphadenopathy, thyromegaly, and JVDHeart:Sinus tachycardiaNormal S1 and S2 and (-) for additional cardiac soundsNo m/r/gLungs:▵ Clear to auscultation bilaterally
12 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 bruitsExtremities (Ext):▵ No CCE▵ Cool and pale▵ Slightly diminished pulses in all extremities▵ Normal ROM throughout▵ DiaphoreticHSM: HepatosplenomegalyBruits: Systolic soundCCE: Clubbing, cyanosis, edemaROM: Range of motionDiaphoretic: Sweating profusely
13 Physical Examination (cont.) Rectum (Rect):▵ Normal sphincter tone▵ No bright red blood visible▵ Stool is guaiac-negative▵ (-) Hemorrhoids▵ Prostate WNL with no nodulesNeuro:▵ 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+ throughoutWNL: Within normal limitsGuaiac: Test to detect fecal occult bloodA&O: Alert and orientedDTRs: Deep tendon reflex
16 Physical Examination (cont.) Chest X-Ray:▵ Anteroposterior view shows heart to be normal in size▵ Lungs are clear without infiltrates, masses, effusions, or atelectasisAbdominal Ultrasound:▵ Non-specific gas pattern▵ No regions of dilated bowlAbdominal CECT:▵ Grade CCECT: Contrast-enhanced computed tomographyAtelectasis: Collapse of a lung
17 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 patientQ8. 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?