3. Drug:
Food:
Allergy history
Basic information │ History │ Examination │ Impression │ Clinical course
─ Personal history
TOCC
Travel history: (Japan)
Occupation history:
Contact history:
Cluster history:
Others
Special environmental exposure:
Pet animal history:
History of venereal disease:
Using behaviors
Cigarette smoking:
‒ 0.25 ppd for 60 years
Alcohol consumption:
‒ quitted for more than 5 years
Betel nut chewing: denied
Denied
Denied
NKA
4. Others
Other systemic disease:
‒ Asthma (w/o drug control)
‒ Renal stone (since 2008)
Operation history:
‒ Lt. upper ureteral stone s/p Lt. ureter
renal scopic lithotripsy and double-J
stent placement (2010)
Immunization history: denied
Underline disease
DM:
HTN:
Family history
Basic information │ History │ Examination │ Impression │ Clinical course
─ Past history
Denied
Drug history
Nil
5. • Rhinorrhea and cough was noted after came back to
Taiwan from Japan
• The patient went to LMD, and some medication was given.
2018/12/23
The 80-year-old married male has history of asthma and renal stone.
Denied DM, Hypertension, heart disease or other disease.
Basic information │ History │ Examination │ Impression │ Clinical course
─ Present illness
• Abdominal pain gradually developed
‒ Located in epigastric region
‒ Dull pain
‒ Onset was not recorded
‒ Eating food and position change didn’t
aggravate or relieve the pain
‒ Accompany symptoms including fever and
tea color urine
‒ Diarrhea, tarry stool, clay color stool, nausea,
or vomiting were denied
2018/12/24
6. 2018/12/27 • Medication was in vain, so the patient came to ER for help
• At ER
‒ Vital signs: BP:133/72, PR:77, RR:20, BT:36.6°C,
SPO2:97%
‒ Lab data showed elevated lipase
‒ CT was arranged which revealed pancreatitis
Under the impression of pancreatitis,
The patient was admitted for further
evaluation and management.
7. HEENT / Neck
Regular heart beats without
murmur
Heart Lung
Abdominal Ext / Neuro
Anicteric sclera, not pale
conjunctivae
Neck: supple, JVE(-), LAP(-)
Symmetric expansion
Breathing sound: clear
Soft and flat, Rebounding pain (-)
Tenderness(+) EPI+RUQ, Murphy’s sign(+)
Hepatomegaly (-), splenomegaly (-)
Normal active bowel sound
EXT: freely movable without pitting edema
Consciousness: clear & oriented
General appearance: fair
GCS: E4V5M6
Vital sign
Date：20181227, Time：1800
BT：36.8℃, PR：65/min, RR：19/min, BP：149/102mmHg
Basic information │ History │ Examination │ Impression │ Clinical course
─ Physical examination
12. Variable Normal Range 12/27 12/28 12/31 01/02
Glucose AC 70-99 mg/dL 221 - 153 -
Amylase 30-110 IU/L 755 486 181 109
GOT 5-35 IU/L 24 18 69 43
GPT 5-35 IU/L 27 22 73 70
CRP 0.010-0.500 mg/dL 12.048 11.063 6.670 -
Lipase 3-67 IU/L 2411 1413 532 294
Cholesterol 0-200 mg/dL - - 164 -
TG 0-150 mg/dL - - 104 -
LDH 95-215 IU/L - 120 -
Ca 8.5-10.0 mg/dL - 8.9 - 10.0
Basic information │ History │ Examination │ Impression │ Clinical course
─ Lab data (Plasma)
1. High level of Glucose AC →Suspected DM
2. Obvious elevated amylase(>360), lipase(>540) and CRP→
Diagnosis of Pancreatitis
3. Elevated GOT and GPT after admitted →???
13. Variable Normal Range 12/27 12/28 12/31 01/02
Glucose AC 70-99 mg/dL 221 - 153 -
Amylase 30-110 IU/L 755 486 181 109
GOT 5-35 IU/L 24 18 69 43
Alk P-tase 30-120 IU/L 63 - - -
T. Bilirubin 0.2-1.5 mg/dL 1.0 1.2 - 0.8
D. Bilirubin 0.1-0.5 mg/dL 0.2 0.2 - -
Cholesterol 0-200 mg/dL - - 164 -
TG 0-150 mg/dL - - 104 -
LDH 95-215 IU/L - 120 -
Ca 8.5-10.0 mg/dL - 8.9 - 10.0
Basic information │ History │ Examination │ Impression │ Clinical course
─ Lab data1. Normal level of direct/ indirect bilirubin and Alk P-tase
→r/o Cholecystitis and Bile duct obstruction
2. Normal level of Cholesterol and TG
→ r/o hyperlipidemia-caused pancreatitis
3. Normal level of LDH and Ca
→Good prognostic factors of pancreatitis
14. Basic information │ History │ Examination │ Impression │ Clinical course
─ Image (CXR)
1. Borderline heart size
2. Tortuous aorta
3. Asymmetric pulmonary hilar
shadows
4. Fibrosis, subsegmental atelectasis,
and opacities of RML field
5. Widening r't upper mediastinum
6. Blunting and opacity superimposed
at right cardiophrenic angle and
medial RLL field
Smoking Aging
15. Basic information │ History │ Examination │ Impression │ Clinical course
─ Image (Abdominal)
1. Massive fecal materials and
bowel gas w/ obliteration of
abdomen.
2. Non-specific bowel gas pattern
over abdomen.
3. Spur formation at spine.
Degenerative change is considered.
16. Basic information │ History │ Examination │ Impression │ Clinical course
─ Image (CT)
1. No definite swelling of the appendix.
2. Relative enlarged pancreas in correlation with his age, compatible with
acute pancreatitis.
3. Mild enlarged prostate.
17. Basic information │ History │ Examination │ Impression │ Clinical course
1. Supportive care
2. Empiric antibiotics
3. Close monitor of vital sign
Plan
1. Acute pancreatitis
2. Asthma (很久沒用藥)
3. Renal stone
Impression
18. Basic information │ History │ Examination │ Impression │ Clinical course
─ TPR sheet
19. Basic information │ History │ Examination │ Impression │ Clinical course
─ POR#
• Kept NPO and massive IV hydration
• F/U lab data showed mild improved WBC and CRP and
prominently decreased amylase and lipase
• The vital signs were stable
• Pain control well
• Abx: Flumarin
2018/12/28
2018/12/29 • Consider closely monitor fever and abdominal pain status
2018/12/30 • Stable, try semi-liquid diet first and F/U DATA tomorrow
20. 2018/12/31 • Abdominal pain after porridge constipation for 5 days
‒ Dulcolax, MgO2 #TID
‒ Sulcrate
‒ Shift to soft diet step by step
‒ IV hydration: Bfluid 1000ml
‒ Pain control: Morphine 10mg/ml inj 0.2 U Q6H prn SC
‒ ABx: Flumarin(12/27~)
• Return to clear liquid
2019/01/02 • Discharge
2019/01/01 • Stable vital sign
• Symptoms improved
30. The main advantage of the APACHE II system is that a score can be derived
at any time during the patient’s hospital course, while the Ranson’s criteria
are only prognostic during the initial 48 hours.
1. Physiologic points
• Temperature
• MAP (Mean Arterial Pressure)
• Heart rate
• Respiratory rate
• Oxygenation (PaO2)
• Arterial pH
• Serum sodium
• Serum potassium
• Hematocrit
• White cell count
• Glasgow coma score
2. Age points
3. Chronic health points :
• Liver
• Cardiovascular
• Respiratory
• Renal
• Immunocompromised
1+2+3 = Total Score
Score ≥ 8 indicate severe pancreatitis
Etiology │ Diagnostic tools │ Score systems │ Treatments
─ APACHE II
32. (A) Axial and (B) coronal views of contrast-enhanced CT demonstrate an
enlarged, edematous pancreatic tail with surrounding inflammatory fat stranding
Etiology │ Diagnostic tools │ Score systems │ Treatments
─ CT severe index
33. (A) Axial view, with associated inflammatory changes throughout the
anterior pararenal space, and (B) coronal view of contrast-enhanced CT show
a large region of parenchymal necrosis (between arrows) involving the
pancreatic tail.
Etiology │ Diagnostic tools │ Score systems │ Treatments
─ CT severe index
34. Etiology │ Diagnostic tools │ Score systems │ Treatments
─ CT severe index
1. No definite swelling of the appendix.
2. Relative enlarged pancreas in correlation with his
age, compatible with acute pancreatitis.
3. Mild enlarged prostate.
35. Etiology │ Diagnostic tools │ Score systems │ Treatments
Fluid resuscitation
• Early aggressive IVF
• Titrate to UOP >0.5 mL/kg/h
• Goal to ↓ BUN & Hct over first 12-24 h
• LR may be superior to NS (↓ SIRS, CRP at 24 h; avoid if ↑ Ca)
Analgesia
• IV opioids
‒ Monitor respiratory status
‒ Adjust dosing if ↑ renal impairment
Nutrition
• Early enteral feeding encouraged (maintains gut arrier,1 bacterial translocation)
• Mild: Start feeding once pain-free w/o ileus.
‒ Low-fat low-residue diet as safe as liquid diet.
• Severe: early (w/in 48-72 h) enteral nutrition indicated and preferred over TPN
‒ ↓ infectious complications, organ failure, surgical interventions, and mortality
• Nasogastric feeding shown to be non-inferior to nasojejunal feeding
