sailordeac Posted August 27, 2012 Share Posted August 27, 2012 Is torsion on the ddx yet? Could consider a u/s with Doppler...it might be able to pick up an appy too without the radiation exposure. Link to comment Share on other sites More sharing options...
chiaroscuro27 Posted August 27, 2012 Author Share Posted August 27, 2012 Great thought, sailordec. I'll also add Mononucleosis to the list. I've seen Mono in kids with abdominal pain and no exudative tonsillitis. I ordered a Monospot and it came back negative. So, ultrasound is out of the question due to time constraints. Your patient is looking sicker every minute and you decide to proceed with CT scan of the abdomen and pelvis with IV contrast. The final report reads as follows: "Acute inflammation of the pancreas, with inflammation of the second portion of the duodenum secondary to pancreatitis. No stones, no pseudocysts, or necrosis." The gallbladder, appendix, spleen, pelvic organs and bowel were all visualized and read as normal, with the exception of the duodenum. Do you still want to call surgery? What tests could you have ordered to rule pancreatitis in or out? What interventions do you make now? Remember, you're in the boonies. Link to comment Share on other sites More sharing options...
Just Steve Posted August 28, 2012 Share Posted August 28, 2012 nice... once again the benefit of case studies shines through. Thanks for spending your time going over this with us. One benefit of being a student is that I have access to UpToDate! via the school library. Just read up on things a little bit...definitely will file this one away as something to keep in mind. I was really under the impression that pancreatitis is a disease of your chronic drinker or sick diabetic. That's what I get for assuming. Looking forward to the next case study Link to comment Share on other sites More sharing options...
chiaroscuro27 Posted August 28, 2012 Author Share Posted August 28, 2012 No problem. I'm happy to do it. I'm 2 months into the job. You can't imagine how huge the learning curve is. I'm as green as they come, but here's some food for thought: - always put horses before zebras. - be aware of how common diseases present, but don't necessarily rule diseases out if the presentation is atypical. - kids and the elderly require extra attention to detail because the presentation can be so different from what you'd expect. - always trust your gut, no matter what the nurses or other ancillary staff think/say/do. - YOU as a non-physician provider must assume responsibility for all the choices you make on the patient's behalf. Don't take this responsibility lightly. - identify early on who the "teachers" are at your hospital/office. I'm lucky to have lots of physician teachers at my beck and call. I ask lots of questions and I learn so much from them and the nurses every day. Don't be too proud to ask questions, and don't be afraid to look stupid every once in a while. So, after we got the confirmation that it was indeed pancreatitis I immediately made arrangements for transfer to the children's hospital in the big city. I had a lovely chat with the pediatric GI folks there who were happy to take the patient in. Kept the girl NPO, kept the fluids going, and provided her some pain medication although she never once asked for it. She was a real trooper! Her amylase was 2991 and her lipase was 2665. Impressive, indeed! This was the first peds case I did on my own from start to finish. I'm just happy it turned out the way it did. It could have easily gone another way. More cases coming soon. Link to comment Share on other sites More sharing options...
flyingsquirrel Posted August 28, 2012 Share Posted August 28, 2012 If we had checked the amylase and lipase, I would have expected them to be high with pancreatitis. Did we get a calcium level? If this is truly a tiny ED in the middle of nowhere, I have a feeling they don't have a peds floor (or pedi surg). I would want to transfer her to a children's hospital. The first order of business is pain/nausea management (which should have been dealt with a long time ago). My first choice would be a fentanyl PCA pump, but something makes me think that isn't going to happen in this ED. Fentanyl boluses +/- ondansetron. Continue maintence fluids, fluid boluses as needed, watch electrolytes carefully. (It's hard to tell from here, but I can't imagine her not needing a fluid bolus at this point after vomiting several times and with the IV contrast.) Watch for ARDS. Transfer to nearest childern's hospital ASAP. Link to comment Share on other sites More sharing options...
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