Date and Time of Interview: June 5, 2016 a 1:00 PM

Source of Referral: None

Source of Information: Patient
Reliability: 95%
Identifying data:
Anas, Amelia, 51 years old, female, married, Roman Catholic, Filipino,
Housewife, currently residing at Brgy. Sta. Fe, Abuyog, Leyte. Admitted for the first
time at EVRMC.
Chief Complaint:
Abdominal pain
History of Present Illness:
2 weeks PTA, patient had intermittent low grade fever.
Four days PTA, patient was apparently well. Sudden onset of sharp steady
and boring epigastric pain that radiates to left and right upper quadrant with pain
scale of 5/10. Not affected by food intake. Patient also had low grade fever which
persisted throughout the day. No vomiting, no diarrhea. Patient took 1 tablet of
naproxen sodium and mefenamic acid and temporary relief noted.
Three days PTA, persistence of epigastric pain thus patient took 1 tablet of
naproxen sodium and mefenamic acid with no relief. At noon, Patient took Aluminum
Hydroxide (Kremil S) but still with no relief. Patient vomited afterwards of food
eaten. Nausea, abdominal distention and loss of appetite noted. Patient took
another tablet of Aluminum Hydroxide (Kremil S) in the evening but still with no
relief.
Two days PTA, persistence of symptoms but now epigastric pain with pain
scale of 7/10, with fever highest at 39 degree Celsius, and dyspnea. Patient did not
take any medications anymore. Just consumed lukewarm water to relieve the pain.
No consult done.
One day PTA, patient went to our center for consult due to unrelieved
epigastric pain, patient was noted to have yellowish discoloration at the abdomen
and yellowish sclera hence admission the next day.
Past Medical History:
Childhood Illnesses: Had mumps, no chicken pox, no measles, no
congenital heart anomalies, no polio myelitis, and no history of tonsillitis nor
rheumatic fever.
Adult Illnesses:
Medical: No previous hospitalization
Surgical: No previous surgical operations
Psychiatric: The patient has no history of psychiatric illness. She is able to
cope effectively whenever problems arise.
Immunizations: could not recall
No known allergies to food or drugs; no previous blood transfusions
Family History:
- Father, 74 years old, with stroke
- Mother, 72 years old, with hypertension
- 4 children all are apparently well.

No family history of DM, cancer, bronchial asthma, thyroid disease, seizure

disorder, nor mental illness

Personal and Social History:

She was born and raised in Sta. Fe, Abuyog, Leyte, and was an elementary
graduate.
She and her family lives in a semi-concrete house, they have toilet facilities
located inside the house. They get water for drinking in a nearby spring. They use
wood for fuel in cooking.
She eats 3x a day with usual meal consists of rice, fish and other seafood.
She has no food preferences. She does not have any exercise regimen.
She is not a cigarette smoker nor alcoholic beverage drinker, not a prohibited
drug user, and no known allergies to any food and drugs. She is not active in any
civic or religious organizations.
REVIEW OF SYSTEM:
General: No weight loss, with body malaise, febrile.
Skin: No rashes, no sores, no itching, no dryness.
Head: No headache, no dizziness, no lightheadedness, no head injury
Eyes: No double vision, no pain, no redness, no excessive tearing, no blurring of
vision.
Ears: No tinnitus, no vertigo, no discharges, no pain, no hearing loss.
Nose: No itching, no colds, no epistaxis, no sinusitis.
Mouth & Throat: no swelling gums, no bleeding, no dryness, no sore throat, no
dysphagia, and no hoarseness of voice.
Neck: No swollen glands, no lumps, no pain, no stiffness.
Breasts: No pain, no lumps, no nipple discharge.
Respiratory: No cough, no dyspnea, no hemoptysis.
Cardiovascular: No chest pain, no palpitations, no orthopnea, no paroxysmal
nocturnal dyspnea.
Gastrointestinal: steady and boring epigastric pain, no dysphagia, no
heartburn, with loss of appetite, defecates once daily with yellow semiformed
stool, no rectal bleeding, no constipation, no diarrhea, no excessive flatulence, no
melena.
Urinary: Urinates approximately 4-6x times daily, of glass per urination,
yellowish in color, no polyuria, no nocturia, no hematuria, no dysuria, no
incontinence.
Genital: No hernia, no discharge, no itching, no sores, no redness.
Peripheral Vascular: No intermittent claudication, no leg cramps, no varicose veins,
no swelling, no redness.
Musculoskeletal: with joint pains, no swelling, no redness, no backache.
Neurologic: No fainting, no seizures, no numbness, no tingling sensation, no

tremors, no vertigo.
Hematologic: No easy bruising, no active bleeding, no history of blood transfusion.
Endocrine: No heat and cold intolerance, no excessive sweating, no polyuria, no
polydipsia, no polyphagia.
Psychiatric: No nervousness, no tension, no depression, no mood swings.
PHYSICAL EXAMINATION: (6th day of hospitalization)
General Survey: Patient seen lying on bed, conscious and coherent, oriented to
time, place and person, cooperative, fairly groomed, endomorph, not in cardiorespiratory distress, febrile and with the following vital signs:
BP- 90/60 mmHg
Integument:

Temp- 38.2 C

PR- 110 bpm

RR- 24 cpm

Skin- Brown complexion, jaundice noted at abdominal area, good skin turgor, no
hypo nor hyper pigmentation, no rashes
Nails Not pale, no clubbing, no ridges, with capillary refill <3 seconds.
Head: Scalp No engorged veins, no scars, no lesion, no tenderness.
Hair Long, black, evenly distributed, neither lice nor nits.
Skull Normocephalic, symmetrical, atraumatic.
Eyes: Eyebrows Symmetrical evenly distributed and black.
Eyelashes evenly distributed, oriented outward.
Eyelids No ptosis, no periorbital edema, no tenderness, no lesion.
Pupils PERRLA 3mm.
Conjunctiva Pinkish palpebral conjunctiva.
Cornea- No ulceration, no lesion.
Sclera Icteric, no lesion, no hemorrhage.
EOM Intact, full movement.
Ears: Symmetrical, no impacted cerumen, no abnormal discharges, no swelling, no
tenderness, no hearing loss.
Nose and sinuses: No septal deviation, pinkish mucous membrane, no nasal flaring,
no lesion, no discharge, no sinus tenderness.
Mouth and Throat: Pinkish lips, no sores, no fissures, pinkish buccal mucosa, no
dentures, no bleeding gums, tongue moves freely, no ulceration, uvula at midline,
no enlargement of tonsils.
Neck: No venous engorgements, trachea at midline, no bruit, no limitation of
movement, thyroid not enlarged, no enlarge lymph nodes.
Breasts: Symmetrical, no lumps, no nipple discharge, no tenderness, no masses.
Chest and lungs: Truncal in shape, no bulging, no retraction of subcostal and
intercostal muscles, symmetrical lung expansion. Confirmed symmetrical lung
expansion, no masses. Resonant in all lung fields. Bronchovesicular breath sounds
in all lung fields, no crackles, no wheezing, no pleural friction rub.
Heart: no precordial bulging. PMI palpable at 5 th ICS left MCL, no thrill, no heaves.

Heartbeat is 110 bpm, regular rhythm, tachycardic, synchronous with the pulse,
no murmurs.
Abdomen:
Inspection: Symmetrical, distended abdomen. No visible peristaltic waves and
pulsations. No bulging flanks or protruding umbilicus. (-) Psoas sign, (-) Obturator
sign
Palpation: Rigid abdomen, liver, spleen and kidney not palpable, no inta-abdominal
masses. Pain upon palpation. (-) Murphys sign, (-) tenderness at McBurneys
point
Percussion: Tympanitic in all regions, No shifting dullness. No fluid wave.
Auscultation: Hypoactive bowel sound. No clappotage.
Extremities: full and equal peripheral pulse, No tenderness.
Back and Spine: No abnormal deviation, no bulging. No tenderness, no mass.
Genital: Grossly female, no discharge and lesion, no swelling.
Neurologic Exam:
Mental Status Examination: Conscious, coherent, cooperative. Oriented to time,
place and person. With good judgment, intact short-term and long-term memory.
Cerebellar: No involuntary movements.
Cranial Nerves:
I
No anosmia
II
Pupils constrict in 3 mm diameter, pupils reactive to direct and consensual
light and accommodation. Good central and peripheral vision.
III, IV, VI- Moves eyes, downward, upward, medially, and laterally (full and intact
EOM).
V
Intact sensory function to touch, intact corneal reflex.
VII
Smiles, able to frown
VIII
Responsive to verbal stimuli.
IX, X
Able to swallow.
X
Able to turn head both sides against resistance, able to lift shoulder
against resistance.
XII
Able to protrude tongue, no right and left deviation, no atrophy and
fasciculation.
MOTOR FUNCTION:
Can flex and extend both upper and lower extremities without limitation, no
atrophy of muscles, no involuntary movements, no spasticity, no rigidity and no
flaccidity.
SENSORY:
Sensitive to pain, touch and pressure on right and left upper and lower extremities,
seen as arousal, withdrawal of tested extremity to pain, and change in facial
expression.
MUSCLE STRENGTH:
-Able to extend both wrist; grip both hands; abduct and adduct fingers; flex and
extend knees, plantar flexes and dorsiflexes ankles. Grade 5/5.
REFLEXES:
Biceps = 2+
Triceps= 2+

Brachioradialis = 2+
Patellar = 2+
Plantar = 2+
PATHOLOGIC REFLEXES:
(-) babinski
(-) ankle clonus
MENINGEAL SIGNS:
(-) Nuchal rigidity
(-) Brudzinskis sign
(-) Kernigs sign
ANS: (-) incontinence, excessive sweating, lacrimation, salivation.

Impression: Acute Pancreatitis

Basis

51 y/o
Female
Endomorph
Steady and Boring Epigastric pain
Pain scale = 10/10
Nausea and Vomiting
With loss of appetite
Fever = 38.2C
Icteric sclera
Abdominal distention
Abdominal Rigidity
Hypoactive to absent bowel sound
(-) tenderness at McBurneys point
(-) Murphys sign
(-) Psoas sign
(-) Obturator sign

DIFFERENTIAL DIAGNOSIS
DIAGNOSIS
ACUTE
CHOLECYSTIT
IS

ACUTE
APPENDICITI
S
PUD

RULE-IN
Low grade fever
Jaundice
Abdominal distention
Hypoactive bowel
sounds
Abdominal rigidity
Epigastric pain
Nausea and vomiting
Fever = 38.2C
Abdominal distention

Epigastric pain
Abdominal distention
Abdominal rigidity

RULE-OUT
Periumbilical pain radiating
to the back
(-) Murphys sign

No migration to RLQ
Tenderness at McBurneys
point
(-) Psoas sign
(-) Obturator sign
Burning abdominal pain
that occurs after meals or
hours afterward.

Nausea and vomiting

Pain typically follows a daily

pattern
Pain not relieved by
antacids

DIAGNOSIS

Amylase and Lipase Test

The two most common tests for diagnosing acute pancreatitis. Serum
amylase and lipase are elevated usually more than three times the upper
limit of normal within 24hours in 90% of cases. Their return to normal is
variable depending on the severity of disease. Lipase remains elevated
longer that amylase and is slightly more accurate for the diagnosis of acute
pancreatitis.
Lipid profile
A panel of blood tests that serves as an initial broad medical screening tool
for abnormalities in lipids, such as cholesterol and TG. Typically includes LDL,
HDL, TG, and total cholesterol. Patient is recommended to fast before
screening. This test is used to identify hyperlipidemia, many forms of which
are recognized.
Ultrasonography
Can provide information on edema, inflammation, calcification, pseudocysts,
and mass lesions. It is a simple noninvasive test useful in diagnosis of
pseudocyst limited by interference by bowel gas.
CT scan
Provides detailed visualization of pancreas and surrounding structures,
pancreatic fluid collection, pseudocyst, degree of necrosis, pancreatic
calcifications, dilated pancreatic ducts, and pancreatic tumors.
Liver Function Test
Acute common bile duct obstruction initially produces an acute increase in
the level of liver transaminases (alanine and aspartate aminotransferases),
followed within hours of rising bilirubin level. This test will help to rule out
other causes of pancreatitis.
TREATMENT
1. Elimination of enteral intake/bowel rest
2. Aggressive fluid repletion
3. Analgesic to relieve pain
4. Lifestyle management
5. Regular physical activity
6. Very low fat diet
7. Low concentrated carbohydrate diet
8. Restriction of alcohol us
9. Smoking cessation
10.Insulin and heparin decreases hepatic production of VLDL while also
increasing hydrolysis of TG by LPL. It also stimulates the synthesis, release
and activation of lipoprotein lipase (LPL) from capillary endothelial cells to
promote triglyceride degradation into FFA for further metabolism or storage.

11.Octreotide inhibits insulin and glucagon secretion. Inhibition of glucagon

secretion may potentiate the fatty acid storing action of insulin and lead to
a greater reduction of serum triglyceride.
12.Plasmapheresis removes serum triglyceride and supplements LPL and
apolipoprotein found in the FFP of the donor plasma. Potential complications
are allergic reaction, and transfusion related infections.
13.Fibrates capable of increasing HDL while simultaneously lowering
triglyceride and are an effective adjunct in treating patients with HTGP who
cannot be managed with diet alone. (gemfibrozil, bexfibrate, fenofibrate).
Toxicities include elevated liver enzyme levels, cholelithiasis, myalgias, and
rhabdomyolisis.
14.Niacin decreases TG levels by reducing hepatic secretion of VLDL and TG
while raising HDL and lowering LDL.
15.Omega 3 fatty acids fish oils and omega 3 fatty acids are effective
adjuncts to other drug therapy as they lead to a decrease in VLDL and lower
endogenously derived TG rich lipoproteins.