DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
ADMITTING DIAGNOSES:
1. Pancreatitis.
2. Diabetes mellitus.
3. Elevated blood pressure.
DISCHARGE DIAGNOSES:
1. Pancreatitis.
2. Diabetes mellitus.
3. Elevated blood pressure.
PROCEDURES PERFORMED: CT of the abdomen and pelvis.
CONSULTANTS: John Doe, MD, Gastroenterology
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old man who has had epigastric pain for approximately one month. He was initially seen as an outpatient and given Nexium, which worked well until approximately two days prior to admission. On the morning of admission, he woke with severe pain. The patient’s wife called for an ambulance. It was noted that he had pancreatitis in the past with a pancreatic abscess. He stated his symptoms felt similar to that.
HOSPITAL COURSE: In the emergency department, the patient was noted to have an elevated lipase, although his amylase was normal. A CT of the abdomen and pelvis was performed, which did not show any inflammation of the pancreas. There was an old fluid collection at the tail of the pancreas, which was felt to be a residual from his previous pancreatitis. He was admitted to the medical floor and made NPO for approximately 48 hours. His pain improved; although, he continued to take morphine 4 mg q.2 hours until approximately 24 hours prior to discharge.
It was noted that when he felt somewhat better, he would go outside and smoke, and he would smoke approximately one packet of cigarettes per day. We cautioned him that the cigarettes might actually be causing gastritis, which could perpetuate his pain. We also explained that we would not be able to discharge him home as long as he was taking morphine. As such, he discontinued his cigarettes and required only one dose of morphine in the following 24 hours. During his last 48 hours in the hospital, he was advanced from NPO status to a clear liquid diet to a soft diet. He tolerated this very well.
His diabetes was followed by Accu-Cheks q.6 hours, and then, when he ate, it was a.c. and nightly. His blood sugar varied from the mid 100 range to an above 200 range. He would follow up with this as an outpatient.
Upon arrival in the emergency department, his blood pressure was elevated at 162/90. He had no history of hypertension. His blood pressure subsequently returned to normal, as his pain was relieved, and it was felt that the elevated blood pressure was due to pain.
DISCHARGE PLANNING:
CONDITION: Stable.
MEDICATIONS: Glucophage, Protonix, Ultram, and Wellbutrin.
DIET: Diabetic diet.
ACTIVITY: As tolerated.
FOLLOWUP: He was instructed to follow up with us in approximately two weeks.
