Day 1:

Ranson’s Criteria vs APACHE Scoring System

Ranson’s criteria are used to predict severity and mortality of acute pancreatitis. 

The criteria with 11 parameters are used to assess the severity of alcoholic pancreatitis. The 5 parameters on admission are age older than 55 years, WBC count greater than 16,000 cells/mm^3, blood glucose greater than 200 mg/dL (11 mmol/L), serum AST greater than 250 IU/L, and serum LDH greater than 350 IU/L. At 48 hours, the remaining 6 parameters are: serum calcium less than 8.0 mg/dL (less than 2.0 mmol/L), hematocrit fall greater than 10%, PaO2 less than 60 mmHg, BUN increased by 5 or more mg/dL (1.8 or more mmol/L) despite intravenous (IV) fluid hydration, base deficit greater than 4 mEq/L, and sequestration of fluids greater than 6 L.

The modified Ranson’s criteria are used to assess gallstone pancreatitis. The five parameters on admission are age older than 70 years, WBC greater than 18,000 cells/mm^3, blood glucose greater than 220 mg/dL (greater than 12.2 mmol/L), serum AST greater than 250 IU/L, and serum LDH greater than 400 IU/L. At 48 hours, the remaining 5 parameters are serum calcium less than 8.0 mg/dL (less than 2.0 mmol/L), hematocrit fall greater than 10%, BUN increased by 2 or more mg/dL (0.7 or more mmol/L) despite IV fluid hydration, base deficit greater than 5 mEq/L, and sequestration of fluids greater than 4 L.

Score Interpretation

0 to 2 points: Mortality 0% to 3%

3 to 4 points: 15%

5 to 6 points: 40% 

7 to 11: nearly 100%

The APACHE-II Score provides an estimate of ICU mortality based on a number of laboratory values and patient signs taking both acute and chronic disease into account.

The APAChe II scoring system takes into account 12 variables (point score ranging from 0-71) which include, (1) Body temperature, (2) mean arterial pressure (mm hg), (3) heart rate(hR), (4) respiratory rate (R.R/mt), (5) Oxygenation (mm hg), (6) Ph, (7) Na (mmol/l), (8) k (mmol/l), (9) Creatinine (mg/100ml), (10) haematocrit, (11) total leucocyte count and the (12) Glasgow coma score. 

Chronic organ insufficiency and immunocompromised include:

• liver insufficiency – cirrhosis, portal htn, hepatic failure, encephalopathy 
• Heart failure 
• Chronic respiratory conditions 
• Dialysis patients
• Immunosuppressed patients 

The major advantage of the APAChe II scoring system is that it can be used in monitoring the patient’s response to therapy while the Ranson and the Glasgow scales are mainly meant for the assessment at presentation.

One limitation of Ranson’s criteria is that other scoring systems are superior in either sensitivity or specificity, In a 2016 meta-analysis, a Ranson’s score greater than 2 had a median sensitivity and specificity of 90% and 67.4% respectively. In this same meta-analysis, other scoring systems had better sensitivity or specificity. For example, APACHE-II score greater than 7 had a 100% median sensitivity, 

The second limitation is that the score and severity of acute pancreatitis cannot be determined until 48 hours have passed since admission. This limits its utility in time-sensitive situations like the emergency department. Also, there are 11 parameters, which makes it difficult to use conveniently. Other scoring systems like APACHE-II can be applied at any time and is the scoring system used in critical care.

The third limitation is that the Ranson’s criteria cannot be used for a pediatric or adolescent population.

https://reference.medscape.com/calculator/apache-ii-scoring-system

https://www.mdcalc.com/apache-ii-score

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5952961/

Day 2:

Acute Diverticulitis Case:

54 y/o male complaining of abdominal pain x2 days.

• Started with crampy intermittent abdominal pain
• Felt like gas pains but has been almost constant pain now
• Left lower quadrant pain, radiates to suprapubic area
• Hurts more with movement 
• Fever – 100.4
• Diarrhea – non bloody
• Does feel constipated in the past 
• Sometimes blood in stool in the past 
• No vomiting 
• No recent travel 
• Steak, meat
• Hasn’t wanted to eat since yesterday 

PMH

• htn on lisinopril 

Denies prior surgery 

Drinks alcohol socially, non smoker 

Family history 

• mom – history of htn and dm
• Dad – alive and well

ROS: Constitutional- fever 

Skin- No rashes, dryness, pruritis, or jaundice. 

Head- No headaches, dizziness, or syncope 

Eyes- No vision changes or pain

Ears- No tinnitus or changes in hearing

Nose- No congestion or rhinitis. No epistaxis.

Mouth/Throat- no throat soreness and dryness. No oral sores or dysphagia. 

Neck- No pain or swelling.

Respiratory- No wheezing, coughing, orthopnea

Cardiovascular- No chest pain, palpitations, edema, or syncope.

GI- As above

GU- No dysuria or hematuria. No nocturia.

Endocrine- No history of diabetes, polydipsia, or polyuria. Heat or cold intolerance.

 

Physical Exam:

Vitals: T-101.4, 

BP- 112/70, 

P-110, 

R- 18

General: Laying in bed, appears uncomfortable with moderate abdominal distension. 

Abdomen: Mildly distended. Bowel is rigid, some guarding. With localizable

tenderness to the left lower quadrant. Bowel sounds are diminished. Tender palpable mass present in the left lower quadrant. No organomegaly

appreciated. No visible hernias. No surgical scars present.

Skin: No jaundice, lesions, or rashes.

Mouth/Throat: Oral mucosa is dry but no erythema, exudates, or masses. 

Neck: Supple without lymphadenopathy.

Lungs: CTABL

CV: RRR, no murmurs or gallops, no lower extremity edema, capillary refill is 3 seconds.

 

CBC

14 > 12 < 200

40

 

CMP

Na 136 

K 3.8

Cl 98

CO2 26

Glucose 86

BUN 26

Cr 0.88

 

Lipase 20

 

Pt/ptt – wnl

CRP elevated 200

 

CT with PO contrast 

Sigmoid wall thickening and adjacent fat stranding – extra-colonic air – 2 cm access