1. CPC 8
Bekah Syverson, Kyle McKenzie, Ashley Thorson, Cody McCorkle, Steve Olson

2. Chief Complaint
My stomach hurts!
Bekah

3. 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
Bekah

4. 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
Bekah

5. Past Medical History, continued
Social History
Married
2 children
Lives in Duluth
Occupational History
Golf course superintendent
Mowing, fertilizing and supervising golf course upkeep
Bekah

6. Review of Systems – Pertinent Positives
Decreased exercise tolerance
SOB after walking 2 blocks
Leg cramps when walking
Relieved with rest
Bekah

7. Physical Exam Vital HEENT BP: 170/110 HR: 86 RR: 14 Temp: 37.2° C
White yellow scales around orbits but not involving the eyes
Bekah

8. 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
Bekah

9. Class Differential Diagnosis
Bekah

10. Our Differential DiagnosisMI
AAA
Hepatitis
Ischemic Colitis
Acute Cholecystitis
Acute Pancreatitis
Bekah

11. 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
Bekah

12. Ruling Out MI ECG: normal Cardiac enzymes: normal Troponin 0.16 ng/ml
CPK IU/L
CK MB 4.5 ng/ml
Bekah

13. Differential: AAA Abrupt onset of upper abdominal/lower chest pain
Smoking: 20 pack year history
Family history of vascular disease
Claudication
Kyle

14. Ruling Out AAA
Abdominal CT: normal
Abdominal Ultrasound: normal
Kyle

15. Differential: Hepatitis
Upper abdominal pain
Tenderness to light palpation in RUQ with rebound and some guarding
Nausea
Kyle

16. Ruling Out Hepatitis Liver Panel Hepatitis Serology
AST 50 (normal: IU/dl)
ALT 14 (normal: 5-40 IU/dl)
Alk. Phos 72 (normal: mg/dl)
GGT 18 (normal: 0-51 U/L)
Total Bilirubin 0.14 (normal: mg/dl)
Hepatitis Serology
negative
Kyle

17. Differential: Ischemic Colitis
Peripheral vascular disease
Smoking: 20 pack year history
Presents as diffuse abdominal pain
Upper abdominal/lower chest pain
Ashley

18. Ruling Out Ischemic Colitis
Abdominal CT
Normal
Fecal Occult Stool Test
negative
Ashley

19. Differential: Acute Cholecystitis
Upper abdominal/lower chest pain following a fatty porketta sandwich
RUQ pain with rebound tenderness
Nausea
Sedentary lifestyle
Ashley

20. Ruling Out Acute Cholecystitis
Liver Panel
AST 50 (normal: IU/dl)
ALT 14 (normal: 5-40 IU/dl)
Alk. Phos 72 (normal: mg/dl)
GGT 18 (normal: 0-51 U/L)
Total Bilirubin 0.14 (normal: mg/dl)
Abdominal Ultrasound
negative
Ashley

21. Differential: Acute Pancreatitis
Upper abdominal/lower chest pain
RUQ with rebound pain and some guarding
Steve

22. Ruling IN Pancreatitis
Liver Panel
AST 50 (normal: IU/dl) - H
Amylase 520 (normal: U/L) – H
Calcium 7.8 (normal: mg/dl) – L
Glucose (normal: <200mg/dl) - H
Lipid Panel
Total Cholesterol (normal: <200 mg/dl) - H
Triglycerides (normal: <150 mg/dl) - H
Lipase Test
630 (normal: U/L) - H
Steve

23. 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
Steve

24. 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
Cody

25. 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
Cody

26. Ranson’s Criteria At Admit Predicts mortality after 48 hours
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
Cody

27. 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!

28. Questions What is the best way to rule out cholecystitis? A) Lab
B) Intuition
C) Abdominal Ultrasound
D) Have patient eat porketta sandwich.

29. Questions
Which of the following is NOT common causes of acute pancreatitis?
A) Elevated Triglycerides
B) Alcohol
C) Cholelithiasis
D) Eating Porketta Sandwich D

30. Questions What are common signs of acute pancreatitis?
A) Mid-epigastric pain
B) Nausea/vomiting
C) Progressive and constant pain
D) Moderately rapid (~30 min) onset of pain
E) all of the above E