Pancreatitis Medical Report: History, Symptoms & 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 a 2-day history of severe abdominal pain. The pain is located in the epigastric region and radiates to the back. It is described as constant and sharp. He also reports nausea, vomiting, and diarrhea. The vomiting is projectile and the diarrhea is watery. He has no fever or chills.

Past Medical History

Mr. Doe has a history of alcohol abuse. He drinks approximately 2-3 beers per day. He also has a history of smoking. He smokes 1 pack of cigarettes per day.

Social History

Mr. Doe is a single man. He works as a construction worker.

Physical Examination

* Vital signs:

* Temperature: 99.8 degrees Fahrenheit

* Pulse: 120 beats per minute

* Respirations: 20 breaths per minute

* Blood pressure: 140/90 mm Hg

* Abdomen:

* Tender to palpation in the epigastric region

* Guarding and rigidity

* Bowel sounds are absent

Laboratory Studies

* Serum amylase: 500 U/L (normal range: 25-125 U/L)

* Serum lipase: 300 U/L (normal range: 10-150 U/L)

* White blood cell count: 12,000 cells/mm3 (normal range: 4,000-11,000 cells/mm3)

Imaging Studies

* Abdominal ultrasound: Shows inflammation of the pancreas.

Diagnosis

Pancreatitis

Treatment

Mr. Doe is admitted to the hospital and started on intravenous fluids and pain medication. He is also given antibiotics to prevent infection.

Prognosis

Mr. Doe's prognosis is good. He is expected to make a full recovery.