clinical case: Acute pancreatitis

TEACHER: ARESTEGUI AGUIRRE DIANA LUZ

Students: - Molina Poblete Sunny Marcelo

-Chavez Guzman Yissell Moodell - Yupanqui Pacheco, Jonathan Wily
-Farfn Gutierrez Danyel
1.- FILIATION:
Name: I.M.G.
Age: 70 years
Address: Urb.Espinar -Jiron 671
Gender: Female
Language: Spanish and Quechua
Race: Mestizo
Occupation: Housewife
Religion: Catolic
Level of Instruction: Complete
Civil status: Connecting
Secondary
Date of Birth: 08-07-1946
Responsible Person: Anglica
Place of Birth: Puno
Mendoza (daughter)
Place of residence: Puno
Admission to hospital: 10/02/17
Login to service: 12/02/17
 Childbirth: Cesarean birth
PATHOLOGICAL PERSONAL
HISTORY
Hospitalizations: Gallstones (2017)
Surgery: Cholecystectomy (2017)

Father: Deceased, unknown cause.

Mother: Deceased, unknown cause
FAMILY BACKGROUND (possible ovarian cancer)
Brothers : 03, living apparently healthy.
Children: 07, living apparently healthy.
BIOLOGICAL FUNCTIONS:
Appetite: Decreased
Sed: Decreased
Depositions: Not since entry.
Urine: Decreased
Dream: No particularities
Sweating: No particularities.

HARMFUL HABITS:
Alcohol: Deny
Coffee: Deny
Tea: Deny
Drugs: Deny
Tobacco: Deny
Kitchen with wood: Yes
Time of illness: 30
days Abdominal pain
Start form: Insidious (colicky)
Course: Progressive Asthenia
Fever
Anxiety
Sickness
Family reports that patient about 30 days ago had colic abdominal
pain, sudden onset, epigastric location, intensity 6/10, with
irradiation to the back and that did not calm with any antalgic
position. In addition, the patient has generalized weakness that
does not allow her to do normal activities, she presents with
nausea, anxiety and fever. She is transferred to the Juliaca hospital
and is diagnosed with acute pancreatitis and is referred to the
regional hospital for treatment on 02/12/17.
 Physical Exam (2/15/17):
PA=130/70 FC=90 FR=24 Sat=77% T: 36.5C W: 70kg

General Status: In REG, REH, REN.

Skin and Faneras: Elastic Tibia, nails in regular state of hygiene with capillary filling less than 3
seconds.
Linf: No lymphadenopathy
CV: RC rhythmic, normofonticos, no murmurs are heard.

TyP: : Audible MV ACP, not RSA

Abd: Flat B / D, RHA present, not painful to superficial or deep palpation, no

palpation masses

Extremities: No Edemas and proper trophism.

Neurological: Awake, preserved upper cerebral functions, isocoric pupils 3/3

mm, No meningeal signs or focalization. ROT.
 CASO CLINICO MEDICINA A

Auxiliary exams: RX of thorax (12/02/17)

 Auxiliary exams : ABDOMINAL ECOGRAPHY

ECOGRAPHIC REPORT (11/02/17)

PANCREAS: Usually normal size, homogeneous
glandular stroma.

CONCLUSION:
PRESENCE OF FREE LIQUID IN ABDOMINAL
CAVITY
REST OF ABDOMINAL ORGANS OF
CONSERVED MORPHOLOGY
CORRELATE WITH CLINICAL CHART
 Auxiliary exams : TEM ABDOMEN AND PELVIS WITH
CONTRAST

TOMOGRAPHIC REPORT (13/02/17)

PANCREAS: With areas of necrosis that
compromises head and body, being the one with
the highest volume at head level of approx. 70cc
presenting internal air component and associated
with peripancreatic fat striation.

CONCLUSION:
ACUTE NECROTIZING COLLECTION (ACUTE
NECROTIC COLLECTION) INFECTED)
FREE LIQUID IN ABDOMINAL CAVITY
PLEURAL EFFUSION AND BIBSAL
CONSOLIDATION
 Treatment
Initial treatments in the hospital may include:

Fasting. You'll stop eating for a couple of days in the hospital in order to give your pancreas a chance to
recover.

Once the inflammation in your pancreas is controlled, you may begin drinking clear liquids and eating bland
foods.

Pain medications. Pancreatitis can cause severe pain. Your health care team will give you medications to
help control the pain.

Intravenous (IV) fluids. As your body devotes energy and fluids to repairing your pancreas, you may
become dehydrated.

Once your pancreatitis is under control, your health care team can treat the underlying cause of your
pancreatitis. Depending on the cause of your pancreatitis, treatment may include:
 Procedures to remove bile duct obstructions.
Pancreatitis caused by a narrowed or blocked bile duct may require procedures to open or widen
the bile duct.

A procedure called endoscopic retrograde cholangiopancreatography (ERCP) uses a long tube with a
camera on the end to examine your pancreas and bile ducts.

Gallbladder surgery. If gallstones caused your pancreatitis, your doctor may recommend surgery
to remove your gallbladder (cholecystectomy).

Pancreas surgery. Surgery may be necessary to drain fluid from your pancreas or to remove
diseased tissue.

Treatment for alcohol dependence. Drinking several drinks a day over many years can cause
pancreatitis. If this is the cause of your pancreatitis, your doctor may recommend you enter a
treatment program for alcohol addiction.
Pancreatitis is an inflammation of the pancreas. This happens when digestive
enzymes begin to digest the pancreas. Pancreatitis can be acute or chronic. Either
way it is serious and can bring complications. Acute pancreatitis occurs suddenly and
usually goes away in a few days with treatment. It is often caused by gallstones.
Common symptoms include severe pain in the upper abdomen, nausea and
vomiting. The treatment is usually fluids, antibiotics and analgesics intravenously for
a few days in the hospital. Chronic pancreatitis does not heal or improve. It
deteriorates over time and leads to permanent damage. The most common cause is
excessive alcohol consumption. Other causes may be cystic fibrosis and other
inherited diseases, large amounts of calcium or fat in the blood, some medications
and autoimmune diseases. Symptoms include nausea, vomiting, weight loss, and
fatty stools. The treatment is usually fluids, intravenous analgesics and artificial
nutrition for a few days in the hospital. After your stay in the hospital, you should take
enzymes and take a special diet. It is also important not to smoke or drink alcohol.