Reason for Follow-Up: The patient was admitted three days ago after presenting with severe abdominal pain, nausea, and vomiting, which was triggered by a high-fatty meal and led to a clinical impression of Acute Pancreatitis.
Clinical Course Summary: N.G. is a 35-year-old White female who came to the ED three days ago with complaints of severe abdominal pain accompanied by nausea and vomiting. The patient described the pain as a constant ache that had a sudden onset and worsened over an hour. The pain occurred in the upper abdomen and radiated to the back. The patient was diagnosed with pancreatitis. She was initiated on aggressive fluid resuscitation with 250ml/hour of 0.9% saline alternating with 5% dextrose. She was also initiated on drug therapy, including IV Tramadol 100 mg for pain relief and Primaxin 500 mg IV q6hr for antibiotic coverage. In addition, she was prescribed IV Ondansetron to alleviate nausea and vomiting.
Since admission, the patient has been administered 10L of NS/D5W. The abdominal pain has been alleviated, and she has been initiated on light oral feeds.
Pertinent diagnostic results include elevated serum amylase, trypsin, and lipase levels, as well as a high leukocyte count, indicating pancreatic cell injury and an underlying inflammatory response.
Review of systems:
General: Positive for fever. Denies chills, malaise, or increased fatigue.
Cardiovascular: Denies palpitations, edema, dyspnea with exertion, or chest pain.
Respiratory: Denies cough, sputum production, chest pain, difficulties in breathing, or wheezing.
GI: Reports nausea, vomiting, and upper abdominal pain radiating to the back.
Genitourinary: Denies pelvic pain, dysuria, blood in urine, urinary urgency/frequency, or abnormal PV discharge.
Physical Exam
Vital Signs: BP- 100-60; HR-108; RR-20; Temp- 100.5F ; SPO2- 99%; HT- 5’4 WT- 182 pounds, BMI- 31.2.
General: Female patient in acute distress. She is well-groomed and appropriately dressed. She is alert and oriented to person, place, and time. She appears nervous, and her speech varies in volume and rate.
Cardiovascular: No edema or neck vein distension. Regular heart rate and rhythm. S1 and S2 are present. No gallop sounds or systolic murmurs are present.
Respiratory: Unison chest rise and falls with smooth respirations. Chest is clear on auscultation,
GI: Soft abdomen with smooth movements on respiration. Diminished bowel sounds in all the quadrants. Abdominal tenderness, distention, and muscular guarding are present on palpation.
Genitourinary: Normal female genitalia. No PV bleeding or abnormal discharge was noted.
Laboratory and Radiology Results
Serum amylase- elevated
Serum lipase- Elevated
Serum trypsin- elevated
Alanine aminotransferase- WNL
BUN- elevated
Complete blood count- increased WBC count
C-reactive protein- elevated
Triglycerides- elevated
Aspartate aminotransferase- WNL
Assessment
The differential diagnoses pending to be ruled out are:
Acute Peritonitis (ICD-10: K65. 0): Peritonitis is an acute inflammation of the visceral peritoneum and endothelial lining of the abdominal cavity. It is mainly caused by infection of the peritoneal cavity by bacteria or chemicals (Kumar et al., 2021). The classic feature of peritonitis is a rigid, board-like abdomen. Abdominal pain is a key symptom and is generally poorly localized, localized, or referred to the chest or shoulder. Other symptoms include nausea, vomiting, anorexia, tachycardia, high fever, dehydration, diminished bowel sounds, decreased urine output, inability to pass flatus, rebound tenderness, and a distended abdomen (Kumar et al., 2021). Peritonitis is a differential diagnosis due to positive symptoms of abdominal pain, diminished bowel sounds, fever, tachycardia, abdominal distension, elevated WBC count, and reactive protein.
Acute Cholecystitis (ICD-10: K81. 0): Acute Cholecystitis is characterized by inflammation of the gallbladder due to gallstones that cause chemical irritation and inflammation. The clinical manifestations include RUQ pain or discomfort often triggered by a high-fat or high-volume meal, nausea, vomiting, fever, anorexia, indigestion, flatulence, abdominal fullness, rebound tenderness, and jaundice (Gallaher & Charles, 2022). Acute Cholecystitis is a differential diagnosis due to pertinent positive findings of upper abdominal pain that began after a high-fat meal, nausea, vomiting, and abdominal distension.
Acute and chronic medical conditions:
Acute Pancreatitis: This is a life-threatening inflammatory process of the pancreas. Symptoms of acute pancreatitis include abdominal pain (mostly radiating to the back), nausea, vomiting, occasional anorexia, and diarrhea. Physical findings include fever, tachycardia, hypotension, abdominal tenderness, muscular guarding distention, diminished or absent bowel sounds, and jaundice (Ashraf et al., 2021). Pancreatitis is associated with respiratory complications, which manifest with dyspnea, tachypnea, and basilar rales. The patient has positive findings of upper abdominal pain radiating to the back, nausea, vomiting, fever, low blood pressure, abdominal tenderness, distention, and muscular guarding.
Treatment Plan
Diagnostics: Abdominal CT scan: This will help to visualize the abdomen and identify any enlargement or inflammation of the pancreas to confirm pancreatitis (Chatila et al., 2019).
Medications:
Continue with:
- IV Tramadol 100 mg for pain relief
- Primaxin 500 mg IV q6hr for antibiotic coverage
- Administer IV Ondansetron 8mg PRN if the patient reports nausea/vomiting.
Consultations: Consult a gastroenterologist if symptoms persist for surgical review.
Health Education: The patient will be instructed to abstain from alcohol consumption to prevent further abdominal pain attacks and worsening inflammation and pancreatic insufficiency. The patient will be informed that alcohol consumption can cause a relapse of acute abdominal pain, and further autodigestion of the pancreas may result in chronic pancreatitis (Chatila et al., 2019). In addition, the patient will be educated on lifestyle practices for weight loss, like a healthy diet and physical exercises, since being overweight and obese are associated with pancreatitis.
Discharge plan: The patient will be discharged if she achieves control of abdominal pain, as indicated by self-report, and has adequate nutrients to meet the body’s metabolic needs (Chatila et al., 2019). The patient will be instructed to report to a healthcare provider if she experiences acute abdominal pain or symptoms of biliary tract disease like yellowing of the skin and sclera, clay-colored stools, or darkened urine.
Geriatric Considerations: If the patient is older (above 65 years), the primary goals of treatment of acute pancreatitis would be the prevention and management of local and systemic complications (Baeza-Zapata et al., 2021). It is recommended to monitor more intensively geriatric patients in the early phase of acute pancreatitis despite the signs of severe disease being absent.
References
Ashraf, H., Colombo, J. P., Marcucci, V., Rhoton, J., & Olowoyo, O. (2021). A Clinical Overview of Acute and Chronic Pancreatitis: The Medical and Surgical Management. Cureus, 13(11), e19764. https://doi.org/10.7759/cureus.19764
Baeza-Zapata, A. A., García-Compeán, D., Jaquez-Quintana, J. O., Scharrer-Cabello, S. I., Del Cueto-Aguilera, Á. N., & Maldonado-Garza, H. J. (2021). Acute pancreatitis in elderly patients. Gastroenterology, 161(6), 1736-1740. https://doi.org/10.1053/j.gastro.2021.06.081
Chatila, A. T., Bilal, M., & Guturu, P. (2019). Evaluation and management of acute pancreatitis. World journal of clinical cases, 7(9), 1006–1020. https://doi.org/10.12998/wjcc.v7.i9.1006
Gallaher, J. R., & Charles, A. (2022). Acute Cholecystitis: A Review. JAMA, 327(10), 965–975. https://doi.org/10.1001/jama.2022.2350
Kumar, D., Garg, I., Sarwar, A. H., Kumar, L., Kumar, V., Ramrakhia, S., Naz, S., Jamil, A., Iqbal, Z. Q., & Kumar, B. (2021). Causes of Acute Peritonitis and Its Complication. Cureus, 13(5), e15301. https://doi.org/10.7759/cureus.15301
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Important information for writing discussion questions and participation
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Hello class and welcome to the class and I will be your instructor for this course. This is a -week course and requires a lot of time commitment, organization, and a high level of dedication. Please use the class syllabus to guide you through all the assignments required for the course. I have also attached the classroom policies to this announcement to know your expectations for this course. Please review this document carefully and ask me any questions if you do. You could email me at any time or send me a message via the “message” icon in halo if you need to contact me. I check my email regularly, so you should get a response within 24 hours. If you have not heard from me within 24 hours and need to contact me urgently, please send a follow up text to
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Your initial discussion post should be a minimum of 200 words and response posts should be a minimum of 150 words. Be advised that I grade based on quality and not necessarily the number of words you post. A minimum of TWO references should be used for your initial post. For your response post, you do not need references as personal experiences would count as response posts. If you however cite anything from the literature for your response post, it is required that you cite your reference. You should include a minimum of THREE references for papers in this course. Please note that references should be no more than 5 years old except recommended as a resource for the class. Furthermore, for each discussion board question, you need ONE initial substantive response and TWO substantive responses to either your classmates or your instructor for a total of THREE responses. There are TWO discussion questions each week, hence, you need a total minimum of SIX discussion posts for each week. I usually post a discussion question each week. You could also respond to these as it would count towards your required SIX discussion posts for the week.
I understand this is a lot of information to cover in 5 weeks, however, the Bible says in Philippians 4:13 that we can do all things through Christ that strengthens us. Even in times like this, we are encouraged by God’s word that we have that ability in us to succeed with His strength. I pray that each and every one of you receives strength for this course and life generally as we navigate through this pandemic that is shaking our world today. Relax and enjoy the course!
Hi Class,
Please read through the following information on writing a Discussion question response and participation posts.
Contact me if you have any questions.
Important information on Writing a Discussion Question
- Your response needs to be a minimum of 150 words (not including your list of references)
- There needs to be at least TWO references with ONE being a peer reviewed professional journal article.
- Include in-text citations in your response
- Do not include quotes—instead summarize and paraphrase the information
- Follow APA-7th edition
- Points will be deducted if the above is not followed
Participation –replies to your classmates or instructor
- A minimum of 6 responses per week, on at least 3 days of the week.
- Each response needs at least ONE reference with citations—best if it is a peer reviewed journal article
- Each response needs to be at least 75 words in length (does not include your list of references)
- Responses need to be substantive by bringing information to the discussion or further enhance the discussion. Responses of “I agree” or “great post” does not count for the word count.
- Follow APA 7th edition
- Points will be deducted if the above is not followed
- Remember to use and follow APA-7th edition for all weekly assignments, discussion questions, and participation points.
- Here are some helpful links
- Student paper example
- Citing Sources
- The Writing Center is a great resource