H&P:

Identifying data:

Name: PS

Sex: Male

Address: Queens

Date of birth: 12/12/1966, 55 y/o   

Date & Time: 2/16/22, 11:00 am 

Location: NYPQ, Internal Medicine

Marital status: Single 

Religion: Christian

Race: Caucasian

Source of information: Self, reliable 

Mode of transport: Self

Chief Complaint: “abdominal and back pain x2 days”

HPI:

PS is a 55 y/o male with a PMHx of HTN, HLD, asthma, alcoholic pancreatitis and chronic alcohol use since 18 y/o presents to the ED complaining of abdominal and back pain for the past 2 days (2/14/22). Patient states the pain started suddenly Monday morning after drinking 3 six-packs of beer Sunday night. Patient states he typically drinks 5 bottles of beer and 1 cup of wine every 3 days but drank more this weekend due to attending a superbowl party. The pain started in his abdomen, worst in the epigastric region, 6/10 in severity, constant, sharp, radiating to his back and associated with nausea and constipation. Patient reports that this pain feels similar to his prior pancreatitis episode 2 years ago. His last bowel movement was 2 days ago (2/14/22) and was soft, brown and non-bloody and patient has been passing gas as usual. Patient has taken Ibuprofen and Tylenol, last taken at 4 am and 8 am respectively, with minimal and temporary relief. Patient states his pain is worse when he lies supine and is better with sitting up. Patient’s symptoms are not worsened or made better with eating. Admits to loss of appetite. Denies fever, chills, vomiting, loss of consciousness, chest pain, dyspnea, urinary complaints, testicular pain or weight loss. Denies any sick contacts.

ED course:

In the ED, patient was started on IV fluids bolus (Lactated Ringer’s), Zofran 4 mg IV, Morphine 4 mg IV and Pepcid 20 mg IV. Abdominal labs and lipase were ordered along with a CT Abdomen and Pelvis with IV contrast to assess for pancreatitis vs bowel obstruction vs other acute etiology.

Initial vital signs –

• Temp: 36.6 C/97.8 F oral
• Pulse: 115 beats/min, regular rhythm
• RR: 20 breaths/min, unlabored
• BP: 163/99
• SpO2 – 97% on room air

ECG – Sinus tachycardia, HR of 110 bpm, no T wave inversions, no ST elevations, normal intervals

Past Medical History:

Asthma – diagnosed 1980

Hypertension – diagnosed 2015

Hyperlipidemia – diagnosed 2015

Past Surgical History:

No past surgical history

Family History:

Mother – HTN. Alive and well

Father – HLD, MI. alive and well

No other significant family history in grandparents or siblings

Allergies:

No known food, drug or seasonal allergies

Medications:

Budesonide-formoterol (Symbicort) 160-4.5 MCG/ACT inhaler – 2 puffs qd  

Albuterol HFA (Proventil;Ventolin) 108 MCG/ACT inhaler – 2 puffs prn

Amlodipine (Norvasc) 5 mg tablet – 1 tablet 5 mg PO qd

Lisinopril 40 mg – 40 mg PO qd

Atorvastatin 20 mg tablet – 1 tablet 20 mg PO qd

Social History:

PS is a single male, lives alone in an apartment, works in maintenance. Admits to alcohol use since age 18, typically drinks 5 bottles of beer and 1 cup of wine every 3 days. Denies tobacco or other illicit drug use. Is currently sexually active with one female partner, admits to using protection. Appetite is usually normal, has had decreased appetite since the pain began. Patient sleeps well, typically 8 hours a night.  Patients tries to go to the gym twice a week. Denies recent travel.

ROS:

General – Admits to loss of appetite since pain onset. Denies generalized weakness, fatigue, weight loss, fever, chills, night sweats.

Skin, Hair, Nails – Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus or change in hair distribution. 

Head – Denies headache, vertigo, head trauma, unconsciousness, coma or fracture.

Eyes – Denies contacts, glasses, visual disturbances, fatigue, lacrimation, photophobia or pruritus. Pt doesn’t know when his last eye exam was. 

Ears – Denies deafness, pain, discharge, tinnitus or use of hearing aids. 

Nose/Sinuses – Denies discharge, epistaxis or obstruction. 

Mouth and Throat – Denies bleeding gums, sore throat, sore tongue, mouth ulcers, voice 

changes, dentures. Pt’s last dental exam was 3 years ago.

Neck – Denies localized swelling/lumps or stiffness/decreased range of motion. 

Breast –Denies lumps, pain or nipple discharge.

Pulmonary System –Denies dyspnea, SOB, cough, wheezing, hemoptysis, cyanosis, orthopnea or PND. 

Cardiovascular System – Admits to HTN. Denies chest pain, palpitations, irregular heartbeat, edema/swelling of ankles or feet, syncope or known heart murmur. 

Gastrointestinal System – Admits to change in appetite since pain onset, abdominal pain radiating to his back, nausea, constipation. Denies intolerance to foods, vomiting, dysphagia, pyrosis, flatulence, eructation, jaundice, hemorrhoids, rectal bleeding, blood in stool, or stool guaiac/colonoscopy/sigmoidoscopy.

Genitourinary – Denies dysuria, hematuria, incontinence, frequency, urgency, oliguria or polyuria.

Sexual History – Admits to current sexual activity with the use of protection. Denies impotence or sexually transmitted infections.

Musculoskeletal System – Denies muscle or joint pain, deformity or swelling, redness.

Peripheral Vascular System – Denies intermittent claudication coldness or trophic changes, varicose veins, peripheral edema or color change. 

Hematologic System – Denies anemia, easy bruising or bleeding, lymph node enlargement or history of DVT/PE. 

Endocrine System – Denies polydipsia, polyphagia, polyuria heat or cold intolerance, goiter or hirsutism. 

Nervous System – Denies seizures, loss of consciousness, sensory disturbances (numbness, paresthesia, dysesthesias, hyperesthesia), ataxia, loss of strength, change in cognition/mental status/memory or weakness (asymmetric). 

Psychiatric –Denies anxiety, depression/sadness (feelings of helplessness, feelings of hopelessness, lack of interest in usual activities, suicidal ideation) or obsessive/compulsive disorder or ever seeing a mental health professional.

Physical Exam:

General: 

55 y/o male is alert and oriented to person, place and time. Is interactive, looks his stated age of 55, is not in acute distress but is in visible discomfort.

Vital Signs: 

BP: 179/104, R arm supine 

R: 20 breaths/min, unlabored 

P: 103 beats/min, regular rhythm 

T: 36.9 C/ 98.4 F (oral)

O2 Sat: 96% on room air

Height – 6’1”

Weight – 122.5 kg/270 lbs

BMI: 35.60 kg/m2

Skin, Hair, Nails and Head:

Skin: Warm & moist, good turgor, smooth texture, non-icteric. No thickness, opacities noted. No lesions, masses, scars or tattoos noted. 

Hair: Average distribution and quantity. 

Nails: No clubbing, capillary refill <2 seconds throughout.

Head: Normocephalic, atraumatic, no deformities and specific faces noted, non-tender to palpation throughout.

Eyes:

Symmetrical OU, conjunctiva normal. Eyebrows and eyelashes even distribution, eyelids have no discharge or swelling, lacrimal glands have no excessive tearing, dryness, enlargement or erythema, lacrimal sac not inflamed or swollen. No strabismus, exophthalmos or ptosis. Sclera white, conjunctiva clear. 

Visual fields full OU. PERRL, EOMs intact with no nystagmus. 

Ears:

Symmetrical and normal size. No lesions, masses or trauma on external ears. No discharge/foreign bodies in external auditory canals AU. Auditory acuity intact to whispered voice AU. Weber midline/Rinne reveals AC>BC AU.

Nose: 

Symmetrical, no masses lesions or deformities, trauma or discharge. Nares patent bilaterally, nasal mucosa pink & well hydrated.

Sinuses:

Non-tender to palpation and percussion over bilateral frontal and maxillary sinuses. 

Mouth: 

Lips – Pink, moist; no cyanosis or lesions.

Mucosa – Pink ; well hydrated. No masses; lesions noted. Non-tender to palpation. No leukoplakia.

Palate – Pink; well hydrated. Palate intact with no lesions; masses; scars.

Teeth – Poor dentition, discoloration of teeth / no obvious dental caries noted.

Gingivae – Pink; moist. No hyperplasia; masses; lesions; erythema or discharge.

Tongue – Pink; well papillated; no masses, lesions or deviation noted.

Oropharynx – Well hydrated; no injection; exudate; masses; lesions; foreign bodies. Tonsils present with no injection or exudate. Uvula pink, no edema, lesions. 

Neck – Trachea midline. No masses; lesions; scars; pulsations noted. Supple; non-tender to palpation. FROM; no stridor noted. 2+ Carotid pulses, no thrills; bruits noted bilaterally, no palpable adenopathy noted.

Thyroid: 

Non-tender; no palpable masses; no thyromegaly; no bruits noted.

Heart:

Regular rate and rhythm. S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated. 

Thorax & Lungs: 

Chest – symmetrical, no deformities, no evidence of trauma. Respirations unlabored, no paradoxical respirations or use of accessory muscles noted. Lat to AP diameter 2:1. Non-tender to palpation throughout.

Lungs – clear to auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus throughout. No adventitious sounds. 

Abdomen: 

Abdomen flat, soft and symmetric with no scars, striae or pulsations noted. Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac or femoral bruits. Epigastric tenderness present and tympanic throughout, no guarding or rebound noted. No Cullen’s or Grey Turner sign. No hepatosplenomegaly to palpation, no CVA tenderness appreciated. Negative Murphy’s sign.

Genitourinary:

Did not complete genitourinary exam

Mental Status:

Patient is awake, alert, oriented and attentive. No slurred speech, aphasia. Good mood and affect. Patient has complete comprehension and insight into his medical problem. Memory and cognitive ability intact, reliable historian.

Nervous System:

Steady gait, no ataxia, balance intact. 5/5 strength throughout, 2+ DTRs.

Peripheral Vascular: 

Skin is normal in color, warm to touch, capillary refill <2 seconds. No calf tenderness bilaterally, equal in circumference. No palpable cords or varicose veins bilaterally. No cyanosis, clubbing or edema bilaterally. DP/PT pulses are 2+.

Musculoskeletal:

No tenderness or soft tissue swelling, ecchymosis, atrophy, or crepitus in bilateral UE and LE. Full PROM and AROM of all extremities. Can lift legs to 45 degrees without difficulty. Can raise both arms to horizontal or above. No evidence of spinal deformities.

Labs: 

CBC:

WBC – 16.32

RBC – 4.78

HGB – 15.2

HCT – 44.2

PLT – 182

MCV – 92.5

MCH – 31.80

Neutrophils – 13.76

Lymphocytes – 1.25

BMP:

Na – 139

K – 3.9

Cl – 100

CO2 – 23

BUN – 15.2

Cr – 0.91

BUN/Cr – 17

Glu – 234

Ca – 8.7

Anion gap – 16

eGFR >90

Hepatic Panel:

Total protein – 7.3

Total albumin –  4.2

Total bilirubin – 1.4

Direct bilirubin – 0.6

AST – 131

ALT – 76

Alk Phos – 165

Lipase – 1,795

Amylase – 392 

Troponin – <0.010

Triglycerides – 311.0

LDH – 305

Procalcitonin – 0.20

PT – 16.2

INR – 1.40

aPTT – 26.3

Differential diagnoses:

1. Acute alcoholic pancreatitis
   1. Patient is a chronic alcohol user for the past 37 years, has a history of alcoholic pancreatitis
   1. Presents with persistent, sharp epigastric pain radiating to his back a/w nausea the morning after drinking 3 six-packs of beer
   1. Patient states this pain feels similar to his prior pancreatitis episode
   1. Patient’s pain is worse when lying down and better when sitting up
   1. On PE, patient has epigastric tenderness and tachycardia to 103
   1. Labs reveal elevated lipase 3x normal and elevated amylase, leukocytosis, elevated glucose, total bilirubin and triglycerides
2. ACS/MI
   1. Patient has a history of HTN and alcohol use which increases progression to atherosclerosis
      1. Heavy binge drinking also associated with higher cardiovascular risk
   1. Family history of MI in his father
   1. Patient presents with constant epigastric pain radiating to the back, nausea, tachycardia
   1. Less likely as patient denies chest pain, pain severity changes based on position, ECG in ED without ischemic changes, negative troponins
3. Unruptured AAA
   1. Patient has HLD and HTN (may à atherosclerosis)
   1. Patient presents with abdominal pain radiating to the back
   1. Less likely as patient is a non-smoker which is the main modifiable risk factor, does not have abdominal bruit or pulsatile abdominal mass on examination
   1. Important to r/o as symptomatic or ruptured AAA requires immediate surgical repair
4. Acute cholecystitis
   1. Patient presents with continuous epigastric pain associated with nausea and anorexia
   1. Could have been precipitated by large meal or fatty food as patient was at a superbowl party the night before pain onset
   1. Patient has leukocytosis with a left shift, elevated total bilirubin, AST, ALT and alkaline phosphatase
      1. LFTs could potentially be elevated due to gallstone pancreatitis but more likely elevated due to alcoholic and fatty liver disease
   1. Less likely as etiology of pain seems to be from alcohol vs large fatty meal, Murphy’s negative on PE
5. Bowel obstruction
   1. Patient presents with epigastric abdominal pain, nausea and constipation
   1. Last bowel movement was 2 days ago
   1. Malignancy is MCC of large bowel obstruction – potential for hepatocellular carcinoma with patient’s extensive history of alcohol use
   1. Less likely as pain is not colicky, abdomen is not distended, patient is passing flatus, bowel sounds are normoactive in all 4 quadrants
6. Peptic ulcer disease
   1. Patient is a male chronic alcohol user which are risk factors for development of PUD
   1. Patient presents with sharp epigastric pain associated with nausea
   1. Less likely as patient’s symptoms have no relationship to eating
   1. Could also potentially be gastritis which presents similarly to PUD

Imaging:

XR Chest Standard (PA, Lat)

• Findings: there is no focal consolidation. The costophrenic angles are sharp. The cardiomediastinal silhouette appears unremarkable. There is mild degenerative disease of the spine.
• Impression: no evidence of acute cardiopulmonary disease

CT Abdomen and Pelvis with IV Contrast

• Findings:
  • Stomach – within normal limits
  • Liver – hypoattenuating hepatic parenchyma, likely reflecting steatosis. Hepatomegaly. Patent portal vein.
  • Gallbladder – not dilated and within normal limits
  • Pancreas – peripancreatic edema, c/w acute pancreatitis. Homogenous pancreatic enhancement w/out evidence of necrosis or devascularization. No associated drainable collection suspicious for abscess.
  • Abdominal aorta – mild atherosclerotic plaque. Normal caliber. SMA/SMV patent.
• Impression: acute pancreatitis with associated peripancreatic edema and trace ascites. No evidence of pancreatic necrosis or abscess. 

Assessment/Plan:

PS is a 55 y/o male with a PMHx of HTN, HLD, asthma and h/o alcoholic pancreatitis with ongoing alcohol abuse since 18 y/o admitted with another episode of acute pancreatitis from recent alcohol use.

#Alcohol induced acute pancreatitis

• Peripancreatic edema c/w acute pancreatitis on CT abd and pelvis
• Hypertriglyceridemia on labs
• Continue with IV fluid (LR 150 mL/hr)
• Morphine prn for pain
• Continue famotidine 20 mg IV q12h
• Start on clears when pain improves
• CIWA protocol for potential withdrawal. Will continue to monitor.

#Leukocytosis, mildly elevated procalcitonin

• Likely related to above, acute inflammatory response
• No suspicion for infection at this time
• Will continue to monitor
• Empiric antibiotics if clinically deteriorates

#Transaminitis

• Likely from alcohol abuse and fatty liver
• No suspicion for gallstone disease

#Alcohol abuse

• Monitor on CIWA protocol
• Requiring minimal current intervention due to low CIWA score
• Started on folic acid 1 mg PO q24h, multi-vitamin 1 tablet PO q24h, thiamine 100 mg IV qd, divalproex 125 mg PO bedtime
• Lorazepam (Ativan) 2 mg/ml injection prn

#Uncontrolled HTN

• Will continue to adjust regimen of Norvasc and lisinopril
• Labetalol 100 mg PO q12h added

#Asthma

• No acute issues
• Use of inhaled bronchodilator prn

#Constipation

• Bowel regimen including added Sennosides-Docusate Sodium 2 tablet PO qd  

#Obesity

• BMI of 34.67
• Discussed with patient. Pt aware of diet and lifestyle issues
• Will consider modification once out of hospital

#VTE Prophylaxis

• Enoxaparin (Lovenox) 40 mg SQ q24h

Patient Education:

I would explain to the patient that based on his presentation, imaging and labs, he has acute pancreatitis, an inflammatory disease of his pancreas due to alcohol use, the second most common cause of acute pancreatitis. Patients with over 5 years of chronic alcohol use are most likely to get this. I’d explain that we’re treating him by giving him IV fluids, pain relieving medications, antiemetics for his nausea and vitamins. Right now you can’t eat anything but we’re going to start a clear liquid diet with slow advancement to solid meals once the pain subsides and you have an appetite. I would provide alcohol use counseling – It’s very important that since your pancreatitis is caused by alcohol, especially since this is your second episode, you stop drinking alcohol. Pancreatitis can be fatal as it can lead to sepsis, a life-threatening complication due to the body’s inflammatory response in fighting this infection, and potentially shock and death. Continued use of alcohol can ultimately lead to other complications including the development of chronic pancreatitis which puts you at an increased risk of developing pancreatic diabetes and pancreatic cancer. I would offer the patient resources including seeing social work to help get him set up with Alcoholics Anonymous or other help and support groups. Additionally, I would stress the importance of dietary changes and weight loss, encouraging the patient to eat foods high in lean protein and low in fat and attempting to exercise more, which would help ease digestion, a function of the pancreas. I would tell the patient that if he feels these symptoms again to go to his nearest emergency department.