SILLIMAN UNIVERSITY MEDICAL SCHOOL

MEDICINE WORKSHEET
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

CANNOT BE RULED OUT

bowel sounds, direct

tenderness of epigastric area,
(+) Cullens sign
Laboratory Examination
Amylase, WBC
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.
DIFFERENTIAL DIAGNOSES

History:
Female gender, age, boring,
constant, severe epigastric
pain radiating to the back; (+)
2 episodes of vomiting; (+)
medical history of chronic
alcoholism, gallstones.

(-) DM, (-) steatorrhea, (-) weight

loss,
(-) chronic abdominal pain, (-)
subcutaneous fat, (-) temporal
wasting, (-) sunken
supraclavicular fossa (-) signs of
malnutrition

Laboratory Examination
CHRONIC PANCREATITIS

PERFORATED PEPTIC ULCER

DISEASE

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

In a perforated PUD, patient

presents with a sudden onset of
severe, sharp abdominal pain and
even slight movement can worsen
the pain tremendously
(-) melena,

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:

DISSECTING ABDOMINAL AORTIC

ANEURYSM

sudden, severe, constant

abdominal pain that radiates to the
back, (+) smoking (14 pack years),
(+) episodes of vomiting,

Physical Examination:

(+) hypotension, tachycardia, (+)

Cullens sign, faint bipedal pulses

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

syncope, (-) sense of impending

doom, (-) murmurs

In AAA, pain is sudden, severe,

constantly located low back, flank,
abdominal or groin area. Onset of
pain is 14 hrs prior to admission,
(-) pulsatile mass in the abdomen,
(-) abdominal bruit or lateral
propagation of an aortic pulse
wave, (+) jaundice

(-) elderly, debilitated patient

(-) urgency to defecate
(-) pain for 30-60 mins after a
meal
(-) bloody stools
(-) Diabetes Mellitus, (-) pain msy
become localized to the RUQ, (-)
Murphys sign
(-) interscapular area radiation
(-) increase pain upon deep
radiation

In appendicitis, pain begins as

periumbilical or epigastric pain
which then migrates to the RLQ of
the abdomen, (+) Cullens sign,
(-) Rovsing sign, (-) Obturator
sign, (-) Psoas sign, (-) Dunphy
sign,
(-) heartburn, (-) regurgitation, (-)
dysphagia, (-) coughing, (-)
hoarseness (-) chest pain, (-)
wheezing

RATIONAL LABORATORY AND DIAGNOSTIC TEST

Test

Normal
Range

Patient's Result

Interpretation/Necessity

Availability

Cos
t

LABOTATORY TEST AND PROCEDURES

COMPLETE BLOOD COUNT
Hemoglobin

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
%

0.7- 1.4 mg/dl

This particularly low in our

patient due to increased red
blood cell destruction and
vitamin B12 deficiency.

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

It is used to determine the

proportion of the patients
blood that is made up of red
blood cells, to screen for,
diagnose, and evaluate the
severity of anemia
This test is used to evaluate
the number of rbcs and to
monitor any number of
diseases that affect the
production or lifespan of the
red blood cells
White blood cell count is done
to evaluate the patients with
possible condition affecting
white blood cells, such as
infection, inflammation, or
cancer.

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

Used to help determine the

cause of or potential for
excessive bleeding, to monitor
and evaluate platelet function,
and to monitor the presence
and effectiveness of antiplatelet medications.
The patients platelet count is
within normal range.
Red blood cell indices are blood
tests that provide information
about the hemoglobin content
and size of red blood cells.
Abnormal values indicate the
presence of anemia and which
type of anemia it is.
Creatinine blood test is used to
assess kidney function and to
monitor the effectiveness of
treatment in patients with long
term metabolic diseases such
as diabetes mellitus and
hypertension.
ALT is measured to see if the
liver is damaged or diseased.
Low levels of ALT are normally
found in the blood.
Alkaline phosphatase (ALP) is

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

an enzyme found in all body

tissues. This test is most often
used to test ALP made in the
tissues of the liver and bones.
Electrolyte tests are used to
identify an electrolyte or acidbase imbalance and to monitor
the effect of treatment on a
known imbalance that is
affecting bodily organ function.

SUMC,
NOPH,HCH

The patient has normal sodium

but low potassium and calcium
levels. This may be due to
disorders that affect absorption
of nutrients from the intestines.
SG: Reflect the relative degree
of concentration or dilution of a
urine specimen. In this case,
the patient has a normal SG.
Blood: The significance of the
'Trace' reaction may vary
among patients, and clinical
judgment is required for
assessment in an individual
case.
pH: Average for normal human
urine is slightly acidic
6.0, however deviations from
normal in any given sample are
unremarkable and consistent,
repeated readings are required
in the top or bottom range to
suggest an abnormality. High
protein diets increase acidity.
Vegetarian diets increase
alkalinity. In this case, the px
has normal pH.
Protein: Normally no protein is
detectable in urine by
conventional methods,
although a minute amount is
excreted by the normal kidney.
A color matching any block
greater than 'Trace' indicates
significant proteinuria. In this
case, the px has a "+" which
could mean a normal minute
amount excreted by the kidney.
RBC: the presence of increased
numbers of erythrocytes in the
urine may indicate a variety of
infections.
Bacteria: this is for detection
UTI, but this has to correlate
well with pus cells to confirm
the infection. In this case, the
px has bacteria which suggest
bacteremia.

SUMC
NOPH
FreeStanding
Labs

290

Mucus threads: has very little

clinical significance. In this
case, the px has abundant
mucus threads which suggest
infection.
RADIOLOGY

ULTRASOUND
OF THE
WHOLE
ABDOMEN

It is used to examine organs in

the abdomen including the
liver, gallbladder, spleen,
pancreas, and kidneys.

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

FINAL DIAGNOSIS: Mild Acute Pancreatitis secondary to

Choledocholithiasis

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

associated diarrhea has been

reported, thrombocytopenia
has been reported

Pneumonias including
hospital acquiredm,
septicemia,
neutropenia, intraabdominal infections,
meningitis, UTI,
gynecological, skin and
skin structure
infections

0)
1g
(P3157.2
0)

MONITORING AND FOLLOW-UP

Stress the importance of follow-up check up. Routine clinical follow-up care (typically including
physical examination and amylase and lipase assays) is needed to monitor for potential
complications of the pancreatitis, especially pseudocysts.
Ensure that the patient responds to the medications and that he continues to receive such
medications on a regular basis, per compliance.
Teach the patient and the significant others how to administer the medications, the dosages, timing
and important preparations before and after every drug administration.
Patient should be seen 7-10 days from discharge to check for signs and symptoms of complication
and to generally see how the patient is faring.
Subsequent imaging studies are indicated to determine if a pseudocyst has developed.

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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