37 Years old Lady with epigastric pain radiated to the back

37 years old Malay lady was brought to the emergency department after developing sudden onset abdominal pain 1 hour prior to admission. The pain is located at the epigastric region and radiated to the back. It is pricking in nature, continuous and slightly relief by bending forward. The pain is grade 6-7 on the pain score and patient did not take anything yet to relief the pain


Questions
1) What is your differential diagnosis
2) List the questions that you want to ask to help you made a diagnosis
3) What investigation that you want to perform for this patient?


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On examination, patient is conscious and alert. she look in pain but not in respiratory distress. Pulse rate is 110 b.p.m, regular rythm and adequate volume. The sclera is jaundiced and conjunctiva is pink. Lung ausculation reveal normal inspiration and expiration with no added breath sound. Apex beat is not displaced and no murmur heard on heart auscultation.


For the abdominal examination, it is non distended, no skin discolaration, no surgical scar, no visible vein or visible peristalsis. The epigastric is tender with guarding. There is no board like rigidity, no mass palpable. bowel sound is heard and normal.


FBC (WBC; 17 X10^3 mm3, Hb; 12 X 10^6 mm3, Plt; 315X10^3 mm3, Hematocrit; 42)

RFT (Na; 135 mmol/l, K; 3.4 mmol/l, urea; 3.6 mmol/l, calcium; 2.01 mmol/l, amylase; 1565 iu/l)

LFT (albumin; 44g/L, globulin 36 g/L, AST 300, ALP 100IU/L, ALT 20 IU/L, TB 10 micromol/L)

Erect chest x ray (no gas under the diaphragm)

ECG (Sinus tachycardia, no ST elevation, no inverted T wave, no Q wave)

Other investigation: pending


Questions


1) What is your provisional diagnosis now?
2) Name two cutaneous sign of the (1) that could be seen on abdominal examination
3) What are the aetiology of (1)
4) Name the complication of the (1)
5) Name the scoring system used to access the severity of (1)



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While waiting for the result to come back, patient was managed at the red zone with close monitoring. However, one hour later, patient’s BP drop to 80/40. Capillary refilling is 3s, heart rate is 130 b.p.m and the patient appears to be confused.

1) What has happened to the patient?
2) How do you manage this patient?

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Patient was admitted to the ICU for further management. On the next following day, her condition worsened and require intubation and triple inotropes. Despite of excessive effort to resuscitate her, she died.