Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are currently a Foundation Year Doctor working in the Emergency Department. Your next patient is Goku San – a 45-year-old gentleman presenting with abdominal pain. Please take a history and perform a relevant examination.
Patient History:
Your name is Goku San – a 45-year-old gentleman who works in a pub.
You noticed in the past two days that you developed a sudden abdominal pain at the top of your tummy and the belly button region. It comes on intermittently, and it is worsening. You described the pain as dull. The pain also radiates towards the back (when this happens, you feel like you are being stabbed with a knife in the back) and is associated with vomiting (no blood/bile – just food content). The pain is 6/10. The pain is worsened by eating food in general. You have tried to use paracetamol to ease the pain, but it hasn't helped that much.
You have had a bad appetite since yesterday and haven't been eating or drinking. You feel sick when you eat – but haven't vomited yet. You are quite constipated lately (no blood/offensive smell in stool /diarrhoea otherwise in previous stools) – haven't been opening your bowel for around 3 days. The stool has not been paler lately or difficult to flush. No urinary problems.
You also have been a little more breathless, but you do not know why. No cough. No fever. No recent trauma. No recent surgery/ procedure. No recent infection. No itchy skin.
Ideas, Concerns, Expectations:
You think this is related to the gallstones. You had similar symptoms in the past. You are concerned if you need any surgery for this as last time, the doctor said they are considering gallbladder removal. You don't want any surgeries; your grandmother died during an operation. You would like to have something to ease the pain.
Past Medical History:
Known to have gallstones and fatty liver, polymyalgia rheumatica (recently diagnosed), hyperlipidaemia, heart failure
Drug History:
Started on steroids 2 days ago, omeprazole, furosemide, statin NKDA
Family History:
Rheumatoid arthritis, gallstones
Social History:
You drink around 2-3 cans of lager per day
Don’t smoke
Live by yourself
Work in a pub
Examination Findings:
Corneal arcus
Tachycardia
Warm peripherals
Appears to be Jaundice/icterus
Epigastric/ umbilical region tenderness with rigidity but no guarding (no signs of peritonitis)
Bowel sound reduced
No signs of ascites
Cullen's sign / Grey Turner's sign
Murphy's sign is negative
Mild pitting oedema bilaterally
Calves soft and non-tender
On chest auscultation – it may show signs of pleural effusion: localised reduced air entry and dullness to percussion/ coarse crackles at bases
Signs of dehydration may include dry mouth, reduced skin turgor, and prolonged capillary refill time
Differentials:
Acute pancreatitis secondary to alcohol/ gallstone/ steroid/ hyperlipidaemia
Cholangitis/ Cholecystitis
Rule out other causes of acute abdomen e.g. peptic ulcer
Decompensated heart failure
To rule out ARDS
To rule out AAA
Investigations:
Bedside:
Observations (low grade pyrexia / tachycardia/ hypoxia/ low sat)
ECG (tachycardia)
ABG e.g. PaO2, lactate, glucose (Glasgow score)
Bloods:
Pancreatitis Glasgow score includes in bloods: WCC (neutrophil) in FBC, LDH/ AST in LFTs, albumin + Calcium in bone profile, glucose, Urea in U&Es
Additionally: CRP (inflammation) + amylase/lipase (raised in pancreatitis – >x3 normal level for amylase, bilirubin in LFTs (may be raised) + other routine bloods to assess for baseline
Blood culture if signs of infection
Emerging test: Urinary trypsinogen-2 (elevated in pancreatitis), Serum IL-6/8 (if raised – may indicate severe risk of pancreatitis)
Imaging:
Abdominal XR (faecal loading / rule out obstruction / perforation)
CXR (acute respiratory distress syndrome / pleural effusions / basal atelectasis)
Ultrasound Abdomen/ endoscopic US (to assess for gallstone/dilated bile duct/ fluid collection/ pancreatic inflammation, peripancreatic stranding, calcification/ biliary sludge)
CT Abdomen +/- contrast – can be diagnostic / assess for complications of pancreatitis e.g. abscess/ fluid collections/pseudocyst/ necrosis + rule out lesions e.g. malignancy) + rule out other causes of acute abdomen
Consider MRCP in gallstone present/ dilatation of biliary tract for further assessment
Special Test:
Fine needle aspiration and culture/biopsy (infected pancreatic necrosis/ unknown lesion)
Management (Acute Pancreatitis):