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Pancreatitis Medical Report: History, Symptoms, and Physical Exam

Medical Report

Patient Information

  • Name: John Doe
  • Age: 50
  • Sex: Male
  • Date: March 8, 2023

History of Present Illness

Mr. Doe presents to the emergency department with 2‑day severe abdominal pain (epigastric, radiating to back), constant and sharp. Nausea, projectile vomiting, watery diarrhea. No fever/chills.

Past Medical History

Alcohol abuse (~2‑3 beers/day), smoking (1 pack/day).

Social History

Single, construction worker.

Physical Examination

  • Vitals: Temp 99.8°F, Pulse 120 bpm, RR 20/min, BP 140/90 mmHg
  • Abdomen: Epigastric tenderness, guarding/rigidity, absent bowel sounds

Laboratory Studies

  • Serum amylase: 500 U/L (normal 25‑125)
  • Serum lipase: 300 U/L (normal 10‑150)
  • WBC: 12,000 cells/mm³ (normal 4,000‑11,000)

Imaging Studies

Abdominal ultrasound: Pancreatic inflammation.

Diagnosis

Pancreatitis

Treatment

Admitted for IV fluids, pain medication, antibiotics (infection prophylaxis).

Prognosis

Good; expected full recovery.

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