Muhamad Na'im B Ab Razak (jacknaim) is a fresh graduate Muslim Doctor from Universiti Sains Malaysia and waiting for the enrollment into the housemanship program. Ambitious in pursuing master program in emergency and traumatology medicine and loves to spent his free time joining humanitarian missions, writing and speaks as an amateur public speaker in motivation and comparative religion. [HOME]

37 Years old lady with epigastric pain radiated to the back


Answer


1) Differential diagnosis

- Acute pancreatitis
- Perforated gastric ulcer or other viscus
- Dissecting abdominal aortic aneurysm
- Ascending Cholangitis
- Viral Hepatitis
- Bowel obstruction (strangulated, volvulus, diverticulum)
- Basal pneumonia
- Inferior myocardial infarction


2) Further question to ask
- Acute pancreatitis (risk factor or aetiology to develop pancreatitis based on mnemonic I GET SMASHED, nausea and vomiting, fever, jaundice, nature of the pain ** mostly dull aching, consistent, radiated to back and relief by leaning forward)

- Perforated gastric ulcer or viscus ( usage of NSAIDs **ask about chronic pain or osteoarthritis which will trigger the patient on history of NSAIDs, more common in elderly, smoker, H. Pylori infection, spent time on bed to relieve the pain, hic cup, history of endoscopic procedure, chronic disease like ulcerative colitis)

- Impending AAA rupture (sudden, severe and constant low back, flank, abdomen or groin pain, syncope, sign and symptom of shock, smoking, COPD, hypertension, patient feel something pulsatile from the abdomen)

- Cholangitis (Charcot triad ** fever, RUQ pain, jaundice*, chills and rigor, abdominal pain, pruritus, history of gall stone disease, recent cholecstectomy, ERCP, history of cholangitis, immunocompromised patient)

- Hepatitis (Influenza like symptoms, anorexia, AGE like symptoms, dark urine, pale color stool)

- Bowel obstruction (Nausea and vomiting, colicky abdominal pain, no flatus production, constipation, distended abdomen)

- Basal pneumonia (pleuritic chest pain, cough, shortness of breath, fever)

- Inferior myocardial infarction (chest pain, palpitation, history of hypertension, diabetes mellitus or heart disease, syncope or near syncope, headache)



3) Investigation for this patient. (based on order of most likely diagnosis. What has been listed here is general information)

a) Blood investigation (FBC, RFT, LFT, PT/aPTT, serum amylase, serum lipase **usually after 3 days of acute pancreatitis, Blood GSH, hepatis serology, CRP & ESR, blood C&S, ABG)

b) ECG

c) Imaging (plain radiograph; CXR, Erect CXR, lateral decubitus x ray, Abdominal X ray., OGDS, ERCP, CT abdomen. Barium meal or double contrast barium enema., abdominal ultrasound)


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