Chief Compliant: The patient is a 50 year old white male with alcoholism who complains of abdominal pain for 4 hours.
History of the Present Illness: Constant, dull, boring, mid-epigastric or left upper quadrant pain; radiation to the mid-back; exacerbated by supine position, relieved by sitting with knees drawn up; nausea, vomiting, low-grade fever, rigors, jaundice, anorexia, dyspnea; elevated amylase.
Precipitating Factors: Alcohol, gallstones, trauma, postoperative pancreatitis, retrograde cholangiopancreatography, hypertriglyceridemia, hypercalcemia, renal failure, Coxsackie virus or mumps infection, mycoplasma infection. Lupus, vasculitis, penetration of peptic ulcer, scorpion stings, tumor.
Medications Associated with Pancreatitis: Sulfonamides, thiazides, dideoxyinosine (DDI), furosemide, tetracycline, estrogen, azathioprine, valproate, pentami-dine.
General Appearance: Signs of volume depletion, tachypnea. Septic appearance. Note whether the patient appears ill, well, or malnourished.
Vital Signs: Temperature (low-grade fever), pulse (tachycardia), BP (hypotension), respirations (tachypnea).
Chest: Crackles, left lower lobe dullness (pleural effusion).
HEENT: Scleral icterus, Chvostek's sign (taping cheek results in facial spasm, hypocalcemia).
Skin: Jaundice, subcutaneous fat necrosis (erythematous skin nodules on legs and ankles); palpable purpura (polyarteritis nodosum).
Abdomen: Epigastric tenderness, distension; rigidity, rebound, guarding, hypoactive bowel sounds; upper abdominal mass; Cullen's sign (periumbilical bluish discoloration from hemoperitoneum), Grey-Turner's sign (bluish flank discoloration from retroperitoneal hemorrhage).
Extremities: Peripheral edema, anasarca.
Labs: Amylase, lipase, calcium, WBC, triglycerides, glucose, AST, LDL, UA.
Abdomen X-Rays: Ileus, pancreatic calcifications, obscure psoas margins, displaced or atonic stomach. Colon cutoff sign (spasm of splenic flexure with no distal colonic gas), diffuse ground-glass appearance (ascites).
Chest X-ray: Left plural effusion.
Ultrasound: Gallstones, pancreatic edema or enlargement.
CT Scan with Oral Contrast: Pancreatic phlegmon, pseudocyst, abscess.
Ranson's Criteria of Pancreatitis Severity: Early criteria: Age >55; WBC >16,000; glucose >200;
LDH >350 IU/L; AST >250. During initial 48 hours: Hematocrit decrease >10%; BUN increase >5; arterial pO2 <60 mmHg; base deficit >4 mEq/L; calcium <8; estimated fluid sequestration >6 L.
Differential Diagnosis of Midepigastric Pain: Pancreatitis, peptic ulcer, cholecystitis, hepatitis, bowel obstruction, mesenteric ischemia, renal colic, aortic dissection, pneumonia, myocardial ischemia.
Disorders Associated with Pancreatitis: Alcoholic pancreatitis, gallstone pancreatitis, penetrating peptic ulcer, trauma, medications, hyperlipidemia, hypercalcemia, viral infections, pancreatic divisum, familial pancreatitis, pancreatic malignancy, methyl alcohol, scorpion stings, endoscopic retrograde cholangiopancreatography, vasculitis.
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