ED Admission

Specialty: Emergency Medicine Specialist REASON FOR PRESENTATION: - Acute onset of severe abdominal pain with associated vomiting. HISTORY OF PRESENTING ILLNESS: - 45yo Female - Daughter, Sarah SMITH, present during consult. - Onset of symptoms: Approximately 6 hours ago, sudden onset. - Description of symptoms: Severe, constant, diffuse abdominal pain, rated 9/10, accompanied by non-bloody, non-bilious vomiting (3 episodes). - Additional relevant symptoms: Patient reports mild dizziness and sweating. - Possible triggers or exposures: Patient consumed a meal at a new restaurant 8 hours prior to symptom onset. - Relevant background information: No prior similar episodes. Patient denies recent travel or sick contacts. - Recent advice or management given by other doctors: Seen by her General Practitioner, Dr. BROWN, yesterday for a routine check-up, advised to continue current lifestyle modifications. REVIEW OF SYSTEMS: - Gastrointestinal: Denies diarrhoea, constipation, or recent changes in bowel habits. No melena or haematochezia. - Cardiovascular: Denies chest pain, palpitations, or shortness of breath. - Neurological: Denies headache, visual changes, or focal weakness. MANAGEMENT EN ROUTE WITH QAS: - Details of treatment provided by QAS Ambulance enroute to Hospital: Administered 1L 0.9% Normal Saline IV. Given 4mg Ondansetron IV for nausea. - Outcome of treatment provided by QAS Ambulance enroute to Hospital: Patient reports slight improvement in nausea but abdominal pain remains severe. PAST MEDICAL HISTORY: - Hypertension, diagnosed 5 years ago. - GORD, managed with PPI. - Cholelithiasis, asymptomatic, diagnosed 2 years ago. - Relevant surgical history: Appendicectomy (aged 12). - Relevant mental health history: No reported mental health conditions. - Specialist involvement: Follows with a cardiologist, Dr. WHITE, for hypertension management. MEDICATIONS: - Amlodipine 5mg OD - Omeprazole 20mg OD ALLERGIES: - Penicillin (rash and hives) SOCIAL HISTORY: - Patient lives with her husband and two children. Works full-time as an accountant. Non-smoker. Occasional alcohol use. DRUG, TOBACCO, ALCOHOL HISTORY: - Relevant alcohol history: Social drinker, ~2 units per week. - Relevant tobacco history: Denies tobacco use. - Relevant social drug use history: Denies illicit drug use. FAMILY HISTORY: - Father had myocardial infarction at age 60. Mother has Type 2 Diabetes. No family history of abdominal surgeries or GI cancers. IMMUNISATION HISTORY: - Up-to-date with routine vaccinations. Received seasonal influenza vaccine 2 weeks ago. EXAMINATION: Vitals: - Weight: 70 kg - Blood sugar level: 6.2 mmol/L - Ketones: Negative - Temperature: 37.8 °C - Blood pressure: 130/85 mmHg - Heart rate: 98 beats/minute - Oxygen saturation: 97% on room air General: Appears acutely unwell, in obvious distress, guarding abdomen. Skin warm and dry. CVS: S1 S2 dual, no murmurs. Capillary refill <2 seconds. Peripheral pulses present and equal. Resp: Clear breath sounds bilaterally, no crackles or wheezes. Respiratory rate 18 breaths/minute, unlaboured. Abdo: Distended, rigid, diffuse tenderness to palpation, worse in epigastrium and right upper quadrant. Guarding and rebound tenderness present. Bowel sounds absent. Neuro: Alert and oriented x3. Cranial nerves intact. No focal neurological deficits. MSK: Full range of motion in all extremities, no gross deformities. INVESTIGATIONS: Bloods: - FBC: WCC 18.5 x 10^9/L (Neutrophil predominance), Hb 13.2 g/dL, Platelets 280 x 10^9/L. - U&E: Na 138 mmol/L, K 4.1 mmol/L, Cr 88 umol/L. - LFTs: ALT 65 U/L, AST 70 U/L, ALP 150 U/L, Bilirubin 1.5 mg/dL. - Amylase: 1200 U/L (High) - Lipase: 950 U/L (High) Microbiology: - Urine Dipstick: Negative for nitrites and leukocytes. Radiology: - Abdominal Ultrasound: Gallstones present in gallbladder, no evidence of acute cholecystitis. Pancreas appears swollen and hypoechoic. - No ECG findings mentioned. - Additional investigations and findings: Awaiting results of abdominal CT scan. ASSESSMENT: - Primary diagnosis: Acute Pancreatitis (likely gallstone-related) - Secondary diagnoses or issues: Dehydration, likely secondary to vomiting. MANAGEMENT IN EMERGENCY: - Details of treatment provided in Emergency Department today: Placed on NBM (nil by mouth). Administered IV fluids (Hartmann's Solution 1L bolus, then maintenance). Given IV Morphine 5mg for pain, with good effect. Repeated Ondansetron 4mg IV. Ordered urgent abdominal CT scan. - Outcome of treatment provided in Emergency Department today: Pain significantly improved to 3/10. Nausea resolved. Patient more comfortable. PLAN: - Admission plan and team assignment: Admit to General Medical Ward under Prof. ROBERTS' team. - Details regards how Admitting doctor was notified: Dr. JOHNSON, registrar for Prof. ROBERTS, was notified by phone at 14:30. - Details regards when the Admitting Doctor will see the patient: Dr. JOHNSON will review patient within 2 hours. - Details of any other Specialist Doctors asked to review patient: Surgical consult requested for general surgery team, Dr. KELLY, to assess for possible endoscopic intervention (ERCP). - Dietary instructions: NBM. - Fluid management plan: Continue IV Hartmann's Solution at 100ml/hr. Monitor urine output closely. - Medication orders: Continue IV Morphine PRN for pain, Ondansetron IV PRN for nausea. Begin IV Proton Pump Inhibitor. - Consults and referrals: General Surgery (Dr. KELLY) for ERCP assessment. Gastroenterology referral for ongoing management. - Monitoring instructions: Frequent vital sign observations (hourly for 4 hours, then 4-hourly). Strict fluid balance. Daily blood tests (FBC, U&E, LFTs, Amylase, Lipase). - Disposition plan: Inpatient admission for acute pancreatitis management.