Acute Pancreatitis Discharge Summary Sample
DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
CHIEF COMPLAINT: Abdominal pain.
HISTORY OF PRESENT ILLNESS: This (XX)-year-old Hispanic male had rapid onset of severe epigastric pain earlier on the day of admission. This was not affected by position. It was somewhat worse with movement and respiration. It was associated with mild nausea. He had no vomiting, diarrhea, melena or hematochezia. He was brought to the emergency department via ambulance. CT scan was done urgently to rule out dissecting aortic aneurysm. It was unremarkable, except for evidence of pancreatitis. He had a serum amylase of 3320 and lipase of 15,060. His peripheral white cell count was 17,400. Bilirubin, alkaline phosphatase, AST, and ALT were normal. See admission history and physical for details.
HOSPITAL COURSE: Gastroenterology consult was obtained. The patient was kept n.p.o. and given parenteral analgesics. His serum amylase and lipase gradually improved. He developed fever. Infectious disease consult was obtained. He was given intravenous Merrem from hospital day #6 through the date of discharge. Abdominal ultrasound showed increased liver size and echogenicity, likely representing fatty liver. The gallbladder was normal. The pancreas could not be well visualized due to the patient’s body habitus and large quantity of overlying bowel gas. The patient continued to have abdominal pain. This was exacerbated by any attempt at taking oral nutrition.
Repeat CT scan of the abdomen on hospital day #5 again showed diffuse pancreatic enlargement, infiltration, and stranding of the anterior pararenal space consistent with pancreatitis. The second CT scan actually appeared to be a little worse than the initial scan. He had progressive pulmonary infiltrates. MRI of the abdomen showed no abnormality other than those consistent with pancreatitis. The patient received peripheral hyperalimentation from hospital day #6 until his discharge. His symptoms eventually subsided somewhat. He was able to take clear liquids but continued to have pain. Eventually, this was controlled with oral analgesics.
DISPOSITION: The patient was discharged home.
DISCHARGE INSTRUCTIONS: He was given instructions on a clear liquid diet. He is to completely abstain from consuming alcohol.
DISCHARGE MEDICATIONS: He was given a prescription for Percocet 5/325 mg 2 tablets p.o. q. 4 h. p.r.n. pain. He was instructed to continue his preadmission medications of Lotrel 5/20 mg daily, Prevacid 30 mg daily, Zocor 80 mg daily, and Finacea cream daily. He is to see Dr. John Doe two weeks after discharge and us one month after discharge.
FINAL DIAGNOSES:
1. Acute pancreatitis.
2. Hypertension.
3. Hyperlipidemia.
4. Atherosclerotic cardiovascular disease.
5. Rosacea.
