Medical Report

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  • Topic: Gastroenterology, Hypertension, Abdominal pain
  • Pages : 2 (289 words )
  • Download(s) : 214
  • Published : March 15, 2013
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Medical Report
Date: 3/9/13
Patient: Darlene Smith
Age: 52
Weight: 251
Height: 5’6”
B/P 100/60
R: 24
T: 101.4
P: 100
Pulse Ox: 97%
Medical History:
Patient is a 52 year old female with a history of gallstones resulting from being diagnosed with cystic fibrosis 5 yrs. ago. Gallstones were removed using ERCP (endoscopic retrograde cholangiopancreatoghrapy). During ERCP doctor discovered patient suffered from a psuedocyst. Patient has no history of pancreas divisium. Patient is currently taking Furosemide due to being diagnosed with hypertension (high blood pressure). At the time she was diagnosed with cystic fibrosis, Mrs. Smith was also diagnosed with rheumatoid arthritis and is currently taking Azathioprine. Patient suffers from acute, chronic pancreatitis. Physical Exam:

Mrs. Smith presented to the ER with acute abdominal pain, nausea and vomiting a moderate amount of mucous. Pt. also has had a fever for 3 days and has complained of fatigue. Tests:
Blood tests revealed high levels of triglyceride (hypertriglyceridemia) and increased calcium levels (hypercalcemia) and hyperlipidemia (excess levels of fat in the blood). Blood amylase levels slightly elevated and decrease in insulin levels also her lipase concentrates were elevated. Ct scan was positive for a psuedocyst. We used a stethoscope to listen for bowel sounds. None were present. Due to the test results patient is diagnosed with acute pancreatitis. An endoscopy was performed to drain the psuedocyst which was a result due to the damage to the pancreas. Diagnosis:

Patient is diagnosis with acute pancreatitis. Admitted to the hospital where pain medication and IV fluids will be administered. Patient will be a NPO (nothing by mouth) until the pancreas is back to normal function. Prognosis:

Patient is expected to recover fully. Recurring attack may be more severe.
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