Assignment Task
Assessment – Clinical Reasoning Cycle
Case Study
Mr Antonio Rossi is a 65 year old Italian man who was brought into ED with complaints of severe midepigastric pain, vomiting and nausea. His wife who is present with him has reported that the pain started the previous day after a family gathering when he had a heavy meal and drank more alcohol than usual. Antonio does not smoke but has moderate to heavy ETOH (alcohol) drinking habits. He has a history of hypertension, hyperlipidemia and Gastro-oesophageal Reflux Disease (GORD) for which his GP has prescribed Caduet 10mg/40mg 1 daily and Esomeprazole 40mg mane.
On examination upon admission:
• BP 138/92 mmHg
• HR 98 beats/min
• RR 22 breaths/min
• Temp 36.2
• SpO2 98%
• Pain score 10/10
• Abdominal assessment – tender in the epigastrium with mild rebound tenderness but no guarding
Lab tests on admission: (reference ranges indicated below in brackets)
FBC:
– Hb 148 (130-180 g/L)
– WCC, 16,000 (5000-10000)
– PMN 75% (60-70%)
Serum Amylase 850 (60-180 units)
Glucose (Random) 7.2 (3.0 – 6.9 mmol/L)
Serum ALP 250 (30- 110 U/L)
Serum Sodium 145 (135-145 mmol/L)
Serum Potassium 4.0 (3.5- 5.2 mmol/L)
Serum Creatinine 62 (60-110 µmol/L
Serum Calcium 2.15 (2.10 – 2.60 mmol/L)
Current diagnosis: Acute pancreatitis
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• Commence IV fluids Glucose 5% at 150ml/hr
• NBM
• Insert Nasogastric tube connected to low intermittent suction
• Morphine 2mg IV bolus PRN for pain
• Ondansetron 4mg IV bolus every 4 hours PRN for nausea
• Ultrasound Abdomen
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