Case Study
Morgan Millett, FNP-S
Client/Source/CC
• Patient is N.S., 28 year old G2 P1 African
American female
• Source was office visit. Patient was 25 weeks
pregnant, coming in for a problem visit.
• Chief Complaint: “abd pain, N/V/D, unable to
keep anything down.”
History of Present Illness
• Patient is a 28 year old G2 P1 female who
presented to the office with complaints of N/V
(c/o she has had since 12 weeks pregnant in which
she has been in and out of the hospital for) that
has worsened over the past week, in which she is
now unable to keep anything down. She also has
diarrhea, upper abd pain, 8/10, weight loss >10%
and fatigue. Nothing makes abd pain better, but
pain is much worse after eating and not relieved
by vomiting. She is unable to work, and barely
able to complete ADL’s. She denies fever, chills, &
being around anyone ill.
What are we thinking ???
• Hyperemesis??? N/V
• GI bug- less likely as she has been sick her
whole pregnancy
• Preeclampsia??? Epigastric pain
• Abruption??? Abd Pain
• Diverticulitis??? Pain
• Pancreatitis??? Pain, Nausea
Past Medical History
• Benign Pancreatic cyst diagnosed in 1999 requiring
surgery x2 to drain, no complications in 10+ years
• Severe hyperemesis with first pregnancy
• Hyperemesis occurs in only about 1% of
pregnancies- however if you have it in your first
pregnancy, there’s a 48% recurrence chance
• No other PMH
Social History
• Does not smoke or use illicit drugs
• Does not drink alcohol
Family History
• Father: HTN
• Mother: None
• Only child
• Has 3 year old daughter at home, healthy.
Allergies & Medications
• Allergies: She has no known drug allergies.
She denies allergies to food, environment, and
latex.
• Medications:
• Prenatal vitamins
Review of Systems
• General: fatigue, weight loss
• Respiratory: Patient denied a history of respiratory
infections, cough, recent chest xray, exposure to TB,
difficulty breathing, wheezing, and night sweats.
• Mouth/Throat: Patient denies taste disturbances,
excessive dryness, and sore throats.
• Cardiac: She denied hypertension, heart murmurs,
chest pains, palpitations, and dyspnea.
• Gastrointestinal: She reports N/V/D, food intolerance,
and abd pain. She denies heartburn and constipation.
ROS continued
• Hematological: Patient denied unusually bleeding/bruising,
history of anemia, and history of blood transfusions
• Neuro/Musculoskeletal: Patient denies headache and pain/neck
stiffness. She denied back pain, paralysis, and deformities.
• Psychiatric: Patient denied a history of anxiety and depression.
She denied nightmares, insomnia and mood changes.
• Endocrine: Patient reported benign pancreatic cyst. She denied
thyroid problems, cold/heat intolerance, polydypsia, and polyuria
• Skin: Patient c/o very itchy skin.
Physical Exam
• General: Underweight, 28-year-old female who
is alert, oriented, and cooperative. FHR 135.
• Vitals signs: T 98.6, BP 110/58, HR 82, R 20, O2
98% on room air. Height: 5’7” Weight: 110#.
BMI 17.2
• Thorax/Lungs: Respiratory rate is equal and
regular. Lungs are clear to auscultation in all
lobes. No rales, rhonchi, or wheezes
appreciated.
Physical Exam Continued
• Cardiovascular: S1 and S2 present in APETM with
bell and diaphragm. Regular apical rate. No heaves,
thrills, murmurs, rubs, or gallops appreciated.
• Abdominal: Gravid, symmetrical, soft. Umbilicus
midline. Auscultation yields bowel sounds x4
quadrants. No aortic, renal, iliac, or femoral bruits.
Difficult to assess for organomegaly r/t pregnancy.
No CVA tenderness, guarding or rebound
tenderness. Pain in RUQ, not worsened or relieved
by pressure, radiating to back.
• Skin: Warm and dry. Visually excoriated r/t patient
constantly itching. Slightly yellow tinged, but otherwise
appropriate for race.
Assessment/Plan
• Admission to hospital- fluids for dehydration
• CMP, CMP, LD & Uric acid, urine analysis (r/o
pre-e & electrolyte imbalances r/t
hyperemesis)
• Ultrasound (r/o abruption)
• Consults: GI & Nutrition
Consult
• Nutrition- recommended TPN during hospital
admission
• GI consult- GI would see her outpatient 4-6
weeks after delivery for f/u on questionable
pancreatic cyst issues
Lab Results
• Patient was anemic- H/H= 7/25
• Her alk phos= 96 U/l (normal 37-98)
• An increase of 2 to 3 times normal alk phos may be
observed in women in the third trimester of pregnancy,
although levels may not exceed the upper limit of the
reference interval in some cases. The additional enzyme is
of placental origin.
• Her albumin (ordered by GI to determine protein
absorbtion r/o kidney & liver diseases)= 2.5 g/dL (3.4-5.4)
• Labs were otherwise all normal.
Differential Diagnosis
• Hyperemesis- N/V, weight loss
• Preeclampsia- likely not r/t labs and BP
• Abruption- likely not r/t normal u/s and no vaginal
bleeding
• Diverticulitis- no fever or bowel issues
• Pancreatitis- nausea, pain
• Kidney/liver diseases
Plan
• Inpatient management until delivery
• PT for to reduce muscle wasting
• Pain management for medications to keep
patient’s pain controlled
• Nutrition: start TPN with lipids
Delivery & beyond
• Patient remained inpatient for 7 weeks and
was induced for worsening weight loss and
pain issues. She had a normal uncomplicated
vaginal delivery of a baby boy at 32 weeks,
who went to NICU.
• She had a rough two day recovery on the
postpartum floor, still having the same
complaints.
• Finally, she had her CT scan…..
Pancreatic Cancer
(157.9)
• Carcinoma of the exocrine pancreas is the 4th most
common cause of cancer deaths in the US.
• It is rarely curable; overall 1 year survival rate is 25%, 5
year is 5%.
• 60-70% of cancers occur in the head of the pancreas
• For advanced or unresectable cancers, survival is <1
year at five years but most patients die within one year
• Median age for diagnosis is 72. Rare < age 45.
Occurrence rises sharply after 45.
Incidence
• In 2009, an estimatd 43470 people were
diagnosed with pancreatic cancer; 35240
deaths.
• AA men 16.7/100,000 AA women 14.4/100,000
• 10.3/100,000 White men & women
Risk Factors
Smoking
Diabetes
Genetic factors
Chronic pancreatitis
Non-O blood type
High intake of dietary fat
Obesity
Alcohol consumption
Clinical Manifestations
• Weight loss- 90%
• Pain- 75%
• Jaundice- 70%
• Diabetes- 15%
• Malnutrition- 75%
• Anorexia- 60%
• Weakness/fatigue- 30-40%
• Dark urine
How is it diagnosed?
• Routine labs may indicate increased serum
bilirubin and alkaline phosphatase, anemia,
and decreased serum albumin
• CT scan using thin section, multiphase
multidetector heliac is choice for diagnosis and
staging.
• Abd U/S: to assess jaundice and duct dilation
Tumor Staging
• Stage I: Limited to the pancrease
• Stage II: Regionally invasive; may involve
lymph nodes but without celiac or mesentaric
artery involvement
• Stage III: Direct involvement of celiac or
superior mesenteric artery
• Stage IV: Distant metastases
Treatment
• Surgical resection: Only chance of cure; no role
for resection in metastatic disease. As few as
15-20% of patients are candidates for resection.
• Whipple procedure: en bloc resection of the
head of the pancreas, distal common bile duct,
duodenum, jejunum, and gastric antrum
• Criteria for unresectability: extrapancreatic
spread, encasement or inclusion of major
vessels, distant metastases.
Management
• Stage I & II: Radical pancreatic resection with
chemotherapy
• Stage III: Chemotherapy and radiation
• Stage IV: Chemotherapy; pain relieving
procedures such as celiac nerve block,
supportive care, palliative decompression
Outcome
• This patient passed away within two months
of her diagnosis.
• Her pregnancy masked common symptoms,
especially because she had hyperemesis with
her first pregnancy.
• CT scan delayed because of pregnancy.
References:
• Berry, L. (2014). Pancreatic Cancer Diagnosis Delayed
in Patients Under 55 Years Old. The Journal of Cancer
Nursing Practice, 13(5), 7.
• De La Cruz, M., Young, A., Ruffin, M. (2014). American
Family Physician, 89(8), 626-32.
• Domino, F. (2014). The Five Minute Clinical Consult,
22nd ed. Philadelphia, PA: Lippincott, Williams, &
Wilkins.
• Hartman, D. J., & Krasinskas, A. M. (2012). Assessing
Treatment Effect in Pancreatic Cancer. Archives Of
Pathology & Laboratory Medicine, 136(1), 100-109.