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Abdominal Pain

Abdominal Pain. CHUA, Mary Francine P. MD080022. Identifying information. R.C. 25 years old Male Filipino Married Dealer Iglesia ni Cristo. Chief complaint. Abdominal pain. History of the present illness. (+) RUQ pain Sudden, intermittent, no radiations

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Abdominal Pain

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  1. Abdominal Pain CHUA, Mary Francine P. MD080022

  2. Identifying information • R.C. • 25 years old • Male • Filipino • Married • Dealer • Iglesia ni Cristo

  3. Chief complaint • Abdominal pain

  4. History of the present illness • (+) RUQ pain • Sudden, intermittent, no radiations • (-) fever, nausea & vomiting, changes in bowel movement • Consult done • UTZ revealed gallbladder stones • Advised surgery but refused • Self-medicated with mixture of apple juice, vinegar & olive oil • Passage of ~70 stones • Complete relief 1 ½ years PTA

  5. History of the present illness • (+) epigastric pain • Occurring ~10 minutes after meals • 5/10, persistent, no radiations • (+) bloatedness • (-) fever, nausea & vomiting, changes in bowel movement • No consult done • Self-medicated with HNBB, AlOH3MgOH2 simethicone, omeprazole with relief 4 days PTA

  6. History of the present illness • (+) epigastric pain • (+) bloatedness • (+) undocumented fever, (-) chills • (+) anorexia • (+) tea-colored urine • No consult done • Self-medicated with HNBB, AlOH3MgOH2 simethicone, omeprazole with relief 2 days PTA

  7. History of the present illness • (+) epigastric pain • 8/10 • (+) bloatedness • (+) undocumented fever, (-) chills • (+) anorexia • (+) tea-colored urine • (+) acholic stools • Consult done at ER • Given paracetamol and omeprazole with temporary relief • Discharged 1 day PTA

  8. History of the present illness Day of admission • (+) epigastric pain • 8/10 • (+) bloatedness • (+) undocumented fever, (-) chills • (+) anorexia • (+) tea-colored urine • (+) acholic stools • (+) yellowing of the eyes • Admission

  9. Review of systems • General: (-) weight loss, fatigue, weakness • HEENT: (-) headache, dizziness, enlarged LN • Pulmonary:(+) dyspnea, (-) hemoptysis, cough, wheezing • Cardiovascular: (-) palpitations, chest pains, orthopnea • Genitourinary: (-) nocturia, dysuria, frequency, hematuria • Musculoskeletal/Dermatologic: (+) back pain, (-) back pain, arthralgia, rashes, pruritus • Endocrine: (-) excessive sweating, heat/cold intolerance, polyuria, excessive thirst

  10. Past medical history • (-) Hypertension, diabetes, asthma • (+) allergies to shrimp and crabs • Unrecalled operation on the head secondary to mauling (1998), with blood transfusion

  11. Family history • (+) Hypertension- father • (-) Diabetes, asthma, TB, cancer

  12. Personal & social history • Married, no children • Diet: rice, “mahilig sa baboy” • Current smoker, 0.8 pack years (2 sticks/day, 8 years) • Heavy alcoholic beverage drinker, ~8 bottles of beer, 3x/week • Marijuana use • High school • Last use: February 2012

  13. General survey • Conscious, coherent, cooperative, in pain • Vital signs • 110/80 mmHg • 104 beats/min • 22 breaths/min • 39.3°C • VAS 8/10 • BMI 19.27 kg/m2 • Weight 59 kilos • Height 175 cm

  14. HEENT • Icteric sclerae, pink conjunctivae • No tragal swelling or tenderness • No nasal discharge • Pink lips, moist oral mucosa, no lesions or sores, (+) multiple dental caries, no tonsillopharyngeal congestion • No cervical lymphadenopathies, non-palpable thyroid gland

  15. Pulmonary • (+) tattoo on the periareolar area, right • Symmetric chest expansion, no retractions • Equal tactile fremiti • No dullness on percussion • Good air entry, clear breath sounds

  16. Cardiovascular • Adynamic precordium • PMI at 5th ICS, left MCL • Normal rate and regular rhythm, distinct S1/S2, no murmurs • No carotid bruits

  17. Abdomen • Flat, soft abdomen, no scars/ lesions • Hypoactive bowel sounds • Tympanitic • (+) epigastric tenderness • Non-palpable liver edge • No palpable masses • (-) Murphy’s sign

  18. Extremities • (+) flushed skin, (+) jaundice • No active dermatoses • Warm extremities • Good skin turgor • Full and equal pulses • No cyanosis, no clubbing • CRT < 2 seconds

  19. Neurologic • Awake, alert, well-groomed • Oriented to 3 spheres • GCS 15 • No cranial nerve deficits • No dysmetria, dysdiadochokinesia • MMT: 5/5 • DTRs: 2+

  20. Salient features • History • Epigastric pain • Bloatedness • Anorexia • Fever • Tea-colored urine • Acholic stools • Gallstones on ultrasound • Heavy alcoholic beverage drinker • Physical examination • High grade fever, 39.3°C • Flushed skin, jaundice • Icteric sclerae • Epigastric tenderness, hypoactive bowel sounds

  21. Initial impression • Obstructive biliary disease, secondary to calculous cholecystitis, to consider choledocholithiasis, ascending cholangitis

  22. Differential diagnoses • Gallstone pancreatitis

  23. Diagnostic evaluation • CBC • SGPT, SGOT • ALP • Bilirubin (direct, indirect, total) • Prothrombin time • APTT • Amylase • Lipase • Ultrasound • Serum electrolytes (Na, K, Cl) • Urinalysis

  24. LGBP Ultrasound • Gallstone with cholecystitis • Dilated common bile duct

  25. Acute cholangitis • One of the main complications of choledochal stones • Ascending bacterial infection due to partial of complete obstruction of the bile ducts • Both bacterial contamination and biliary obstruction are requisites for its development • E. coli, Klebsiella pneumoniae, Streptococcus faecalis, Enterobacter, Bacteroides fragilis

  26. Clinical presentation • Mild, intermittent and self-limited to fulminant, potentially life-threatening septicemia • Most common: Charcot’s triad (2/3) • Fever • Epigastric/ RUQ pain • Jaundice • Reynold’s pentad • Septic shock • Mental status changes • On abdominal examination, the findings are indistinguishable from those of acute cholecystitis

  27. Tokyo Guidelines • A. Clinical context/ manifestations • History of biliary disease • Fever ± chills • Jaundice • Abdominal pain (RUQ/epigastric) • B. Laboratory data • Evidence of inflammation • WBC, CRP • Abnormal LFTs • ALP, GGT, AST, ALT • C. Imaging • Biliary dilatation or evidence of etiology • Stricture, stone, stent • Suspected Dx: • >2 in A • Definitive Dx: • Charcot’s triad • >2 in A + both B and C

  28. Tokyo Guidelines • Mild • (+) response to medical treatment • General supportive care and antibiotics • Moderate • No response to medical treatment • No onset of organ dysfunction • Severe • No response to medical treatment • (+) Onset of organ dysfunction • CVD: BP, need for vasopressors • Nervous: consciousness • Respiratory: PaO2/FiO2 <300 • Kidney: Creatinine > 2 mg/dL • Liver: PT-INR >1.5 • Hematologic: Platelets <100

  29. Management • Endoscopic retrograde cholangiopancrea-tography (ERCP)

  30. Management • Laparoscopic cholecystectomy

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