Case Clerking 5

Saturday, January 8, 2022 1:09 AM

PATIENT’S NAME
Francis Gan Teck Heng
RN: 35981296

DATE OF ADMISSION
6/1/2022 (Inpatient, Ward 7U)

DIAGNOSIS
Acute pancreatitis

Differentials:
- Myocardial infarction
- Gastritis
- Peptic ulcer disease
- GERD
- Gastric cancer

SUMMARY HISTORY OF THE PATIENTS CONDITION

Chief complaint
Mr. Francis Gan is a 61 year old Chinese gentleman presented in Surgery Ward, admitted on 5/1/22 due to chief
complaint of central chest and epigastric pain of 1 day.

History of presenting complaint

Mr. Francis first complained of gradual onset of central chest pain around the sternal area and epigastric pain
which radiates to the lower back on the night of 5/1/22, described as sharp and constant with a pain score of 8/10,
and getting worse. The pain is relieved by sitting up and leaning forward, but gets worse when supine.

The pain is associated with onset of vomiting after his breakfast on 6/1/22. He claims to have had a total of 4
episodes of vomiting in a span of 4-5 hours, though it only consists of food particles. He also experienced
diarrhoea described as loose stools in the same time span for a total of 4 episodes, described as lighter brown
colour compared to his normal stools. He did not complain of any other constitutional, UGI, LGI, hepatic, or anemic
symptoms.

He went to UMMC's Emergency Department on 4/1/22 after the pain was described as unbearable.
Mr. Francis currently reports feeling well and is currently in no pain, and has had no more episodes of diarrhoea.
However he claims to have had dark-coloured urine in his urinary drainage bag for the past 2 days he was
admitted in the ward

Past medical history

Mr. Francis was previously diagnosed with hypertension and dyslipidemia roughly 30 years ago, but does not
perform regular blood pressure monitoring at home. He has a history of stroke which occurred on 3/11/221
(experienced weakness on entire left side of body at night, next morning experienced left sided hemiparesis,
admitted to UMMC and underwent physiotherapy, speech therapy and neuro aid).

Drugs
Hypertension: Perindopril
Dyslipidemia: Atorvastatin
Stroke: Aspirin
Allergies
Claims to be allergic to seafood (shellfish) and to sulfur-based medications
Family history
Mr. Francis has no relevant GI family history. He does have a family history of stroke where his father passed
away, while his sister is currently undergoing treatment for stomach cancer.

Social history
Mr. Francis is a social drinker, but does not smoke or take recreational drugs. He is a part-time phone wholesaler.
He is married and has 2 children. He currently lives with his wife and children in Damansara Jaya. He exercises
frequently through daily morning walks and squash once a week. There is no recent travel history.

EXAMINATION OF ALL SYSTEMS

General inspection
Upon general inspection, Mr. Francis appears well, conscious, alert, with no anxiety or respiratory distress, and is
able to ambulate.

There is a cannula attached to his right dorsum, but he is not attached to any medical equipment.
Peripheral examination
There are no fingernail abnormalities, finger clubbing, muscle wasting, pallor, palmar erythema, dupuytren's
contracture, tremors, or hepatic flap. There were no tattoos or injection sites on the arm, and no scratch marks,
bruising, petechiae, or ecchymosis, or loss of axillary hair.

CRT was <2 seconds, and pulse was regular, while palms were warm to touch.
There was no scleral icterus or xanthelasma or conjunctival pallor. There was no angular stomatitis, glossitis,
parotidomegaly, ulceration or central cyanosis during examination of the tongue and oral cavity.

Chest examination
There were no other skin changes or scars or swelling or gynaecomastia or spider naevi.
Abdominal examination
Abdomen was slightly distended, with no flank fullness or asymmetrical movement during breathing. There were no
scars or swellings or masses, stomata or fistula, dilated veins, obvious peristalsis or pulsations or ulcerations.

There were no hyperaesthetic areas palpable or masses palpable in all 9 quadrants during palpation.
Liver edge and spleen were not palpable. Liver span was 10cm. Kidney was not ballotable. There was no shifting
dullness or sacral edema, while auscultation of vessels showed no bruits, and there were normal bowel sounds.
There was no pedal edema.

Neck examination
There were no palpable lymph nodes or swellings in the neck region.
Ideally, I should complete the examination with digital rectal examination, external genitalia examination, and
hernial orifices examination.

RELEVANT INVESTIGATION(S)
Complete blood count (differential) - to check WBC count to assess for infection/inflammation
Serum amylase - increased in pancreatitis
Serum lipase - increased in pancreatitis
Renal function test - to assess urea/creatinine level and serum electrolytes to check for signs of dehydration
Liver function test - to check the baseline liver function and rule out liver disease
Blood glucose level - sudden onset of diabetes can indicate pancreatitis
CRP - marker of severity of pancreatitis
ABG - for marker of severity
CT/MRI abdomen - to assess for stones or enlarged pancreas
Endoscopic ultrasound - to assess for stones
ECG/cardiac enzymes - to rule out MI
OGDS/barium meal - to rule out gastritis/peptic ulcer

OUTCOME / PROGRESS

Mr. Francis is scheduled to be discharged on 9/1/22 as he is now well. Upon discharge, he was prescribed with
pantoprazole, tramadol, and metoclopramide. He is scheduled to come again in 2 weeks for follow-up at the HPB
clinic and for a liver function test.