Scenerio #1 - Abdominal pain

Did the ERCP reveal anything? Possible Gall stones?
 
Let's see.

I'm having a high suspicion for pancreatitis, which is a possible complication of the ERCP test. The slightly elevated (depending on source) amylase and lipase values would support this, along with the fever and onset over a few days. Did they leave something in there?
 
The x ray does reveal inflammation around the pancreas and the diagnosis of pancreatitis is correct. In addition, the pt. has a significant WBC count with left shift indicating acute bacterial infection. The elevated lipase should have really been the clue though as it is specific to pancreatic enzymes. General rule of thumb, if its elevated, its your pancreas.

So what is the PRIMARY cause of this lady's illness? I've heard possible complications secondary to the ERCP. Anyone else have any thoughts?

How about the current rehydration plan? Any problems that you see?

We've identified the hypokalemia and the hypocalcemia. Any other electrolyte issues?

anyone want to try the bonus question????
 
I'll take my shot at this.

Patient is an alcoholic and therefore already has chronic pancreatitis.

The fact that she had a cholysectomy, perhaps indicates a poor diet (high in fats) which also can cause pancreatitis.

The fact that she has not been taking "the meds" that were prescribed after the procedure, I'm assuming they were antibiotics, would have allowed the infection to grow.

The elevated WBC would simply be from fighting the infection.

The woman needs to taper off the alcohol, change her diet, and take meds that are prescribed to her for good reason.
 
Her rehydration plan needs to account for the low potassium. The low potassium is what is causing the neurological effects (speech lethargy)

Her sodium level is borderline high. Maybe they should be rehydrating with KCl instead?

The abundance of Na and the lack of K have many effects at the cellular level.
 
Hey Paramedics! The Basics are kicking your a$$es on this one!


Yes, the Sodium is also an issue and 0.9% NaCl is not the best choice for rehydration. 0.45% would be a better option, prefereably with a little KCl added (which is what we did for her).

The alcoholism is the primary cause of her pancreatitis. Yes an ERCP has a 5%ish chance of causing it, but will usually do so within 3-5 days. Diet can also play a part.

something else to notice is her HTN history. Believe it or not, antihypertensive agents, especially calcium channel blockers and diuretics, can cause the condition.

Bonus ?? anyone???????

Awesome responses thus far. I guess I'm making it too easy!
 
Flight-LP said:
Hey Paramedics! The Basics are kicking your a$$es on this one!


Yes, the Sodium is also an issue and 0.9% NaCl is not the best choice for rehydration. 0.45% would be a better option, prefereably with a little KCl added (which is what we did for her).

The alcoholism is the primary cause of her pancreatitis. Yes an ERCP has a 5%ish chance of causing it, but will usually do so within 3-5 days. Diet can also play a part.

something else to notice is her HTN history. Believe it or not, antihypertensive agents, especially calcium channel blockers and diuretics, can cause the condition.

Bonus ?? anyone???????

Awesome responses thus far. I guess I'm making it too easy!
Click to expand...
Cr 2.6
high risk for temporary renal failure with contrast CT...
 
silver said:
Cr 2.6
high risk for temporary renal failure with contrast CT...
Click to expand...

**bowing down** We're not worthy.....................

Awesome!!!!

In addition to the possible renal issues, IV contrast is known to prolong and complicate acute pancreatitis (disputed heavily, but generally accepted as feasible and concerning).

Thanks for playing, job well done!

More to come....................
 
This was a great scanario to follow. A great indication of just how much I have no idea about yet, but very interesting. Thanks to all who participated.
 
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