The stem
A 62-year-old woman with known gallstones has had severe epigastric pain radiating to the back for 12 hours, with vomiting. These results are taken 48 hours after admission.
Laboratory reportSpecimen: blood
| Test | Result | Units | Reference |
|---|---|---|---|
| Lipase | 2,450 H | U/L | 13 – 60 |
| White cell count | 17.2 H | ×109/L | 4.0 – 11.0 |
| Glucose (random) | 214 H | mg/dL | 70 – 140 |
| Urea | 52 H | mg/dL | 17 – 43 |
| Calcium (corrected) | 7.6 L | mg/dL | 8.6 – 10.2 |
| Albumin | 3.6 L | g/dL | 3.8 – 4.4 |
| LDH | 520 H | U/L | 120 – 250 |
| ALT | 210 H | U/L | 0 – 41 |
| PaO2 (room air) | 72 L | mmHg | 80 – 100 |
Typical adult reference ranges, with hospital ranges for ALT and albumin. Always read results against your own laboratory’s ranges.
The examiner’s questions
Question 1What is the diagnosis, and how is it confirmed?Show the model answer
Acute pancreatitis. Two of three criteria are needed: typical pain, lipase or amylase above three times the upper limit, and typical imaging. This patient has the first two.
Question 2Which result points to the cause?Show the model answer
The ALT of 210 U/L. A rise in ALT above about three times normal early in the illness strongly suggests a gallstone cause, which fits her known gallstones.
Question 3Calculate the modified Glasgow (Imrie) score.Show the model answer
Score 4: age over 55, white cell count over 15, glucose over 180 mg/dL (10 mmol/L), and calcium below 8 mg/dL (2 mmol/L). PaO2 is above 60 mmHg, urea is below 96 mg/dL (16 mmol/L), albumin is above 3.2 g/dL and LDH is below 600 U/L, so they do not score. A score of 3 or more predicts severe pancreatitis.
Question 4How do you manage her?Show the model answer
High-dependency care, goal-directed intravenous fluids, analgesia, oxygen, urine output monitoring and early feeding. Antibiotics only for proven infection. ERCP if cholangitis develops. Cholecystectomy is planned to prevent recurrence.
After you answerThe teaching pointShow
The level of lipase or amylase confirms the diagnosis but does not measure severity. Severity is judged by the scores, organ failure and their trend.
The patients and results are written for teaching and do not belong to real patients.