Saturday, November 19, 2016

42 year old man with abdominal pain (Presented by 3rd semester Prodymna Kundu)

Presented by 3rd semester Prodymna Kundu)

 A 42 year old man admitted to the hospital presents with complaints of 



•  Pain in the abdomen 


He had severe pain radiating downwards and laterally from the tip of xiphoid process. The pain is centered mostly around the epigastric and umbilical regions. It had a sudden onset. Pinching sensation. Coughing aggrevates the pain. When perspiring the patient felt giddiness. Nausea present. Episodes of vomiting were there. Before admission he was administered analgesics. Appetite is there but there is a feeling of anorexia. Increased chromacity of urine.

He had an anal fistula 8 years back.

He has trunkal obesity.
   
The patient is diabetic  (DM -2 )for the last 6 years. Non Insulin taker.

Blood pressure normal 

TB, Epilepsy, Asthma  -  Negative 

No surgical history 

Mixed diet 

Regular and adequate sleep

Irregular bowel and bladder movement  (no stool passed for 3 days) 
Appetite is normal 
Addicted to smoking( 7 no per day ) 
No history of blood transfusion.



OBJECTIVE 

Abdominal Inspection: 







Clinical examination for Ascites: 

Abdominal X ray: 






Amylase                         774
Lipase                             4632




CECT Abdomen: 









   Serum potassium         3.4
  Serum sodium              134
  Serum chloride            99
  Serum calcium             7.4 
  Total bilirubin               1.2
  Albumin:Globulin         1.7 :1

SGOT                                39
SGPT                               117
GGT                                 430
ALP                                 123
Cholesterol                     110
Triglycerides                  99
HDL                                 25
LDL                                  69

Conversational Clinical decision support: 


Comments
Denis English He was in his 3rd semester?
UnlikeReply1November 19 at 10:59pm
Boudhayan Dm Can we get our Radiology teachers to explain the findings in the CT Abdomen using teaching slides or videos regarding the exact findings . Invite Nidhi Sehgal Maam and Kishore Mandal Sir to the discussion. If we could learn abt CT scoring of Pancreas keeping this patient in mind and seeing reference images to get a more practical insight into what terms like fat stranding really mean
UnlikeReply1November 20 at 8:35amEdited
Nidhi Sehgal Based on these ct images...acute pancreatitis (modified ct severity index 4)
UnlikeReply1November 20 at 8:41am
Rakesh Biswas Boudhayan, Prodymna would be good to search and share some images that depict acute pancreatitis CT severity indices under the guidance of Dr Nidhi.
LikeReplyNovember 20 at 1:10pm
Rakesh Biswas
Write a reply...
Boudhayan Dm Harsh Tevethia Invite Sir to the discussion. Could you kindly teach the MBBS students regarding the abdominal pain characteristics in Acute Pancreatitis and the possible mimics and how to differentiate. Also inviteArka De Sir for his inputs on how gall stones actually lead to pancreatitis and whether or not the etiology can affect the severity. Invite Our Gastroenterologist Sir Dr. Dipendu Mazumder to kindly tell us how the CT Scan images help us in deciding the treatment modalities
UnlikeReply1November 20 at 8:51am
Boudhayan Dm All abt Acute Pancreatitis http://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-acute-pancreatitis............Arka De Sir can u kindly help us with access to this article
LikeReplyRemove PreviewNovember 20 at 8:56am
Boudhayan Dm Nidhi Sehgal Maam Sharing a few images .....I would request you to kindly share more teaching images if available and explain the findings in each for the learning of the students . https://radiopaedia.org/articles/acute-pancreatitis
LikeReply1November 20 at 9:01amEdited
Rakesh Biswas Thanks Dr Nidhi thesehttp://www.radiologyassistant.nl/.../pancreas-acute... images that you shared are very helpful to understand the severity grades. Ours looks like interstitial pancreatitis with some swelling/edema and peripancreatic inflammation (manifested in the margin irregularity?) and fatty infiltration (manifested by?). Would it add up to 2 points or 4? Just wondering (i am not an expert).
LikeReplyRemove PreviewNovember 20 at 1:19pm
Nidhi Sehgal Ascitis is there... So...2+2.
UnlikeReply1November 20 at 1:42pmEdited
Nidhi Sehgal https://radiopaedia.org/articles/modified-ct-severity-index
Modified CT severity index | Radiology Reference Article | Radiopaedia.org
The modified CT severity index is an extension of the original CT severity index (CTSI) was developed by Balthazar and colleagues in 1994 for distinguishing mild, moderate and severe forms of acute pancreatitis. The original CT severity index ha...
RADIOPAEDIA.ORG|BY ADITYA SHETTY
UnlikeReplyRemove Preview2November 20 at 1:59pm
Boudhayan Dm For all the UGs in 3rd semester- First comes Pathology........The relevant literature from Robbins textbook Pathology for you all..... https://webfiles.uci.edu/.../public/RBP9%20Chapter%2016.pdf Would request Senior Professor Dr. Debdatta Basu to discuss the possible theory and practical EXAM questions from this topic ....An important aspect for the students keeping in mind the exams they HAVE to appear for
UnlikeReply1November 20 at 2:26pm
Boudhayan Dm Would request the Dr. Gaurav Kaushal ( Welcome Sir to the discussion. Sir is my senior from JIPMER from the dept of Surgical Gastroenterology) to discuss the surgical aspects in Acute Pancreatitis specifically and in Gall stones induced Pancreatitis in General.... From Bedside to Management
LikeReplyNovember 20 at 2:29pm
Boudhayan Dm Rakesh Biswas Rahul Jain Dr.muhammed Yasin. Dipendu MazumderWould request the teachers to kindly discuss the fluid management in case of Acute Pancreatitis with relevant supportive literature and guidelines
LikeReplyNovember 20 at 2:41pm
Dipendu Mazumder The preferred initial fluid is RL owning to its bicarbonate content and stable PH it prevents development of metabolic acidosis compared to NS
UnlikeReply1November 20 at 3:01pm
Boudhayan Dm Here follows some literature regarding FLUID MANAGEMENT IN ACUTE PANCREATITIShttp://www.pancreapedia.org/.../fluid-resuscitation-in...
LikeReplyRemove PreviewNovember 20 at 3:01pm
Boudhayan Dm Another reference onehttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC4277949/
Fluid resuscitation in acute pancreatitis
Acute pancreatitis remains a clinical challenge, despite an exponential increase in our knowledge of its…
NCBI.NLM.NIH.GOV
UnlikeReplyRemove Preview1November 20 at 3:04pm
Boudhayan Dm Till we get the inputs Inputs on the timing of sugery in Acute Biliary Pancreatitis http://www.pancreapedia.org/.../timing-of-cholecystectomy...
UnlikeReplyRemove Preview1November 20 at 3:06pm
Rakesh Biswas Another article added from here:https://www.ncbi.nlm.nih.gov/.../PMC.../pdf/WJG-20-18092.pdf by Dr Dipendu. The last author of that article was my thesis guide. Boudhayan it would be even more important to discuss and take stock of the fluid management of our current patient here shared by Prodymna. Can you share the fluid I/O charts here?
LikeReply1November 20 at 3:23pm
Boudhayan Dm I am not in hospital Sir presently
LikeReplyNovember 20 at 3:25pm
Rakesh Biswas We need to have a system to access that data. 
LikeReplyNovember 20 at 3:45pm
Rakesh Biswas
Write a reply...
Boudhayan Dm Another aspect I wanted to highlight was the hypocalcemia observed in this patient . Can I request the teachers from Biochemistry Dept Dr. Arindam Ghosh to throw more light on this aspect. . Providing a link to a recent article https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4810896/
LikeReplyRemove PreviewNovember 20 at 7:57pm
Boudhayan Dm EXAM QS---- Mechanism of Gall Stone Pancreatitis( My viva qs during my 2nd yr University Viva examination)https://www.bioscience.org/2001/v6/af/A697/fulltext.htm
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