DAVAO MEDICAL SCHOOL FOUNDATION, INC.

– COLLEGE OF MEDICINE
Department of Internal Medicine
Name: Chloe Lynn M. Gotera
Batch/Section: NMD 4 Date: July 16, 2022

DAY 5 ACTIVITY

Instructions:
 Strictly use Harrison’s Principles of Internal Medicine 20th edition, Bate’s Guide to Physical Examination and History Taking, or Clinical Practice Guidelines as your reference in
answering this case. You may also use the official textbooks used by other departments.
 Indicate the name of the book, chapter and page number in the reference column. Failure to write the reference will incur deduction from the total grade.

Question Answer Reference

What is necrotizing
pancreatitis?
How do you manage
necrotizing pancreatitis?
What are the common
causes of acute
 Inflammation associated with parenchymal and/or peripancreatic necrosis
 Pancreas blood supply interrupted
 Severe form
 occurs in 5–10% of acute pancreatitis admissions and may not evolve until several
days of hospitalization. It is characterized by lack of pancreatic parenchymal
Harrisons 21st ed Chap 348 p 9728
enhancement by intravenous contrast agent and/or presence of findings of
of the entire ebook
peripancreatic necrosis. The natural history of pancreatic and peripancreatic
necrosis is variable because it may remain solid or liquefy, remain sterile or
become infected, and persist or disappear over time. Importantly, those with only
extrapancreatic necrosis have a more favorable prognosis than patients with
pancreatic necrosis (with or without extrapancreatic necrosis).
 Percutaneous fine-needle aspiration of necrosis with Gram stain and culture was
previously performed to evaluate for infected pancreatic necrosis in those with
sustained leukocytosis, fever, or organ failure
 Empiric antibiotics should be considered in those with clinical decompensation
 Pancreatic drainage and/or debridement (necrosectomy) should be considered for
definitive management of infected necrosis, but clinical decisions are ultimately
Harrisons 21st ed Chap 348 p 9736
influenced by the clinical response since almost two-thirds of patients respond to
of the entire ebook
antibiotic treatment with or without percutaneous drainage.
 A more conservative approach to the management of infected pancreatic necrosis
o it is recommended to do so for 4–6 weeks to allow the pancreatic
collections to either resolve or evolve to develop a more organized
boundary (i.e., to “wall off”) so that surgical or endoscopic intervention is
generally safer and more effective.
 Gallstones: most common cause Harrisons 21st ed Chap 348 p 9718
 Alcohol: 2nd most common cause of the entire ebook

PREPARED BY: M. PLATERO, RN, MD, FPCP 1

 DAVAO MEDICAL SCHOOL FOUNDATION, INC. – COLLEGE OF MEDICINE
pancreatitis?
What is BISAP score?
Can we determine the BISAP
score of this patient? Justify
your answer.
What is Cullen’s sign?
Explain the pathophysiology.
What is Turner’s sign?
Explain the pathophysiology.
Question
What is the prognosis of this
patient?
What are the signs that your
patient is recovering?
What will be your home or
discharge medications?
e.g. Amoxicillin 500 mg/tab 1
PREPARED BY: M. PLATERO, RN, MD, FPCP
Department of Internal Medicine
 HyperTriglycerides (usually with serum triglycerides >1000 mg/dL)
 Endoscopic retrograde cholangiopancratography (ERCP) IM Plat p 139
 Drugs
 Trauma
 Postoperative
 Sphincter of Oddi dysfunction
 BISAP (> 3 of these factors: associated with increased risk for in-hospital mortality)
o B: BUN >25 mg/dL
o I: Impaired Mental Status (GCS <15)
IM Plat p 141
o S: SIRS: > 2 of 4 present
o A: Age > 60 years
o P: Pleural effusion
 We cannot determine the BISAP score of this patient because based on the factors
presented, History taking was not completed and labs were not also completed.
 Blue discoloration around the umbilicus (results from hemoperitoneum) IM Plat p 140
 Blue-red-purple or green-brown discoloration of the flanks (reflects tissue
catabolism of hemoglobin) IM Plat p 140
 The discoloration may be green, yellow, or purple depending on the degree of red
NCBI
blood cell (RBC) breakdown in the abdominal wall tissues and may not occur until https://www.ncbi.nlm.nih.gov/books/NBK534296/
several days into the course of an illness.
Answer Reference
Harrisons 21st ed Chap
 Mild acute pancreatitis has a very low mortality rate <1% 348 p 9728 of the entire
ebook
 After 3–7 days, even with continuing evidence of pancreatitis, total serum amylase values
tend to return toward normal. However, pancreatic lipase levels may remain elevated for 7–
14 days. It should be recognized that amylase elevations in serum and urine Harrisons 21st ed Chap
 Serum lipase is now in normal state. Serum lipase activity increases in parallel with amylase 348 p 9728 of the entire
activity and is more specific than amylase, making it the preferred test. A serum lipase ebook
measurement can be instrumental in differentiating a pancreatic or nonpancreatic cause for
hyperamylasemia
Harrisons 21st ed Chap
 Treat symptoms as needed
348 p 9728 of the entire
o Paracetamol 500 mg 1 tab every 4 hours
ebook
2
 DAVAO MEDICAL SCHOOL FOUNDATION, INC. – COLLEGE OF MEDICINE
Department of Internal Medicine
tab 3 x a day for 7 days
When will you discharge this Harrisons 21st ed Chap
 Patient should undergo CBC again to check for the serum amylase, lipase, wbc, and etc.
patient from the hospital? 348 p 9728 of the entire
When these normalize, patient could be discharged.
What will be your basis? ebook
Harrisons 21st ed Chap
What is your COMPLETE
 Mild acute pancreatitis with mild dehydration 348 p 9728 of the entire
FINAL DIAGNOSIS?
ebook

COMPLICATIONS TREATMENT (answers in bullet format/keywords or main points) Reference (Source, p. no.)
 Percutaneous fine-needle aspiration of necrosis with Gram stain and culture
 Empiric antibiotics should be considered in those with clinical decompensation
 Pancreatic drainage and/or debridement (necrosectomy) should be considered for
definitive management of infected necrosis, but clinical decisions are ultimately
influenced by the clinical response since almost two-thirds of patients respond to
Harrisons 21st ed Chap 348 p
 Necrosis (sterile or infected) antibiotic treatment with or without percutaneous drainage.
9736 of the entire ebook
 A more conservative approach to the management of infected pancreatic necrosis
o it is recommended to do so for 4–6 weeks to allow the pancreatic
collections to either resolve or evolve to develop a more organized boundary
(i.e., to “wall off”) so that surgical or endoscopic intervention is generally
safer and more effective.
 The incidence of pseudocyst is low, and most acute collections resolve over time.
 Pancreatic fluid collections (pseudocyst, Less than 10% of patients have persistent fluid collections after 4 weeks that would Harrisons 21st ed Chap 348 p
abscess) meet the definition of a pseudocyst. Only symptomatic collections require 9737 of the entire ebook
intervention with endoscopic or surgical drainage.
 Placement of a bridging pancreatic stent for at least 6 weeks is >90% effective at
resolving the leak with or without parenteral nutrition and octreotide. Nonbridging Harrisons 21st ed Chap 348 p
 Pancreatic ascites
stents are less effective (25–50%) but should be considered with parenteral 9737 of the entire eboo
nutrition and octreotide prior to surgical intervention.
 The treatment of obstructive jaundice depends on its cause. Clogged or narrowed Harrisons 21st ed Chap 348 p
 Obstructive jaundice bile or pancreatic ducts may be relieved by inserting a stent using ERCP 9737 of the entire eboo

Lifestyle modifications or
nonpharmacologic interventions in term What will you advise to this patient? Reference (Source, p. no.)
of (e.g. exercise):

PREPARED BY: M. PLATERO, RN, MD, FPCP 3

 DAVAO MEDICAL SCHOOL FOUNDATION, INC. – COLLEGE OF MEDICINE
Department of Internal Medicine
Harrisons 21st ed Chap
 Clear or full liquid diet has been
 Drink lots of fluids (water) 348 p 9727 of the entire
recommended for the initial meal
ebook
 Cut all the fat that you can see (eat poultry like chicken/duck/turkery without the skin) Harrisons 21st ed Chap
 Low fat diet  Eat fish (salmon, etc. Rich in omega 3) 348 p 9727 of the entire
 Bake, broil or grill meat instead of frying in oil/butter ebook

HOME MEDICATIONS PRESCRIPTION FORM

Name of Patient: M.R. Age: 45 Sex: Male
 Include the brand Address: Bajada, Davao City Date: July
name that you prefer 17, 2022
to use.

Example:

amoxicillin (Himox)
500mg/tab tab # 21
sig. 1 tab orally 3 x a day 1. Paracetamol (Biogesic) 500mg
for 7 days sig. 1 tab every 4 hours as needed for fever, headache or abdominal pain

Doctor’s Name: Chloe Lynn Gotera

License #: 123 789
PTR #: 987 321

LIST ALL THE PROBLEMS OF THIS

PATIENT (History, PE, Diagnostic test How did you manage the problem? Give a brief description of your management Reference (Source, p. no.)
results)
 Intravenous narcotic analgesics to control abdominal pain and supplemental
oxygen (2 L) via nasal cannula
 Abdominal pain 9/10  Intravenous fluids of lactated Ringer’s or normal saline are initially bolused at 15– Harrisons 21st ed Chap 348
20 mL/kg (1050–1400 mL), followed by 2–3 mL/kg per hour (200–250 mL/h), to
maintain urine output >0.5 mL/kg per hour
 Tachycardia, Tachypnea  Treat symptomatic fever to control vital function to normal level Harrisons 21st ed Chap 348
 Start broad-spectrum antibiotics in a patient who appears septic while awaiting the
 Fever results of Gram stain and cultures. If cultures are negative, the antibiotics should Harrisons 21st ed Chap 348
be discontinued to minimize the risk of developing opportunistic or fungal

PREPARED BY: M. PLATERO, RN, MD, FPCP 4

 DAVAO MEDICAL SCHOOL FOUNDATION, INC. – COLLEGE OF MEDICINE
 Nausea and vomiting
 Abdominal tenderness
 Abdominal distention
 Mild dehydration
 Serum Amylase
 WBC
PREPARED BY: M. PLATERO, RN, MD, FPCP
Department of Internal Medicine
superinfection
 The most important treatment intervention for acute pancreatitis is safe, aggressive
Harrisons 21st ed Chap 348
intravenous fluid resuscitation. The patient is made NPO to rest the pancreas
 Intravenous narcotic analgesics to control abdominal pain Harrisons 21st ed Chap 348
 Patient made NPO Harrisons 21st ed Chap 348
 Gave aggressive intravenous fluid resuscitation
 Intravenous fluids of lactated Ringer’s or normal saline are initially bolused at 15–20
Harrisons 21st ed Chap 348
mL/kg (1050–1400 mL), followed by 2–3 mL/kg per hour (200–250 mL/h), to
maintain urine output >0.5 mL/kg per hour.
 Gave aggressive intravenous fluid resuscitation Harrisons 21st ed Chap 348
 Antibiotic treatment Harrisons 21st ed Chap 348
5