What are the key things to assess and check on physical examination (PE) of a patient with suspected pancreatitis who is receiving maintenance Intravenous Fluids (IVF)?

Physical Examination Assessment for 14-Year-Old with Suspected Pancreatitis on Maintenance IVF

Your physical examination should focus on detecting signs of clinical deterioration, complications, and adequacy of fluid resuscitation, with particular attention to abdominal findings, vital signs stability, and evidence of organ dysfunction.

Vital Signs and Hemodynamic Assessment

• Monitor for persistent tachycardia, hypotension, or fever as these indicate inadequate resuscitation or developing complications 1
• Assess for signs of fluid overload including pulmonary edema, peripheral edema, or jugular venous distension, as excessive fluid administration has detrimental effects 1
• Check oxygen saturation to detect early respiratory compromise 2
• Evaluate for signs of shock requiring escalation of care beyond maintenance fluids 1

Abdominal Examination

• Assess for worsening abdominal distension and tenderness, particularly epigastric tenderness, as these are adverse clinical features 1
• Check for peritoneal signs including rebound tenderness and guarding, which indicate severe disease and may suggest complications 3
• Palpate for an epigastric mass, which suggests an acute fluid collection that may persist to form a pseudocyst 1
• Look for body wall ecchymoses including Cullen's sign (periumbilical) or Grey-Turner's sign (flank), which indicate severe hemorrhagic pancreatitis 4
• Assess bowel sounds as prolonged ileus is an adverse clinical feature 1

Respiratory Assessment

• Auscultate lungs bilaterally for decreased breath sounds or crackles suggesting pleural effusions or ARDS 1
• Observe respiratory rate and work of breathing as respiratory failure is a sign of septic complications 1

Neurological and General Assessment

• Evaluate mental status and level of consciousness as altered sensorium may indicate organ dysfunction 1
• Assess pain level using validated scales (VAS, VRS, or NRS) to guide analgesic management 2
• Check for signs of dehydration including dry mucous membranes, poor skin turgor, and capillary refill time to assess adequacy of fluid resuscitation 1

Signs of Complications Requiring Urgent Action

• Monitor for sudden high fever (as opposed to unremitting low-grade fever common in necrotizing pancreatitis), which may indicate infected necrosis 1
• Assess for signs of cardiorespiratory or renal failure as these indicate septic complications 1
• Look for persistent vomiting which suggests fluid collection development 1
• Evaluate for the clinical picture of "failure to thrive" - a patient requiring continued system support with features of hypermetabolism and catabolic state suggesting complications 1

Key Clinical Pitfalls to Avoid

• Do not rely solely on clinical assessment as it is unreliable and may misclassify around 50% of patients 4
• Recognize that unremitting low-to-moderate grade fever alone does not necessarily indicate deterioration in necrotizing pancreatitis 1
• Be aware that clinical evaluation may be more difficult if the patient requires intensive monitoring 1