Writing and Pronunciation—Pancreatitis Medical Report

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South Medical Center
Douglas, Ga.
History and Physical
Patient Name: Armando Tabouya
Patient Number: 2012-1645-0
Birth date: 09-14-61
HISTORY AND PRESENT ILLNESS: Mr. Tabouya was diagnosed with Cystic Fibrosis and Pancreas Divisum at birth. These diseases have caused the patient to have Gallstones which were found and removed by ERCP 2 years ago. During the administering of the procedure the physician discovered the patient to have a pancreatic pseudocyst. The treatment for this condition was drainage with an endoscope. The onset of Hypertension (high blood pressure) was detected in the patient 5 years ago and he has been taking Furosemide (lasix) since the detection. He has also been taking Azathioprine for help with his weak immune system and to aid his rheumatoid arthritis. The patient’s history also shows low levels of triglyceride and was diagnosed with Hypertriglyceridemia, and has a severe case of pancreatitis. The patient may have a history of alcoholism. SYMPTOMS: The patient came in complaining of chronic abdominal pain, along with vomiting, and feeling exhausted. PHYSICAL EXAMINATION FINDINGS: Due to the patient being obese, blood tests were ordered and the findings of elevated levels of lipids and too much calcium were noticed. Therefore the diagnosis of hyperlipidemia and a reasonable recognition of hypercalcemia were established. Because of the new and pre-existing conditions another blood test was ordered to check the insulin levels. We determined there was a decreased level of insulin, along with a small increased level of blood amylase which is parallel to the lipase prognosis. This led us to the conclusion that the patient is suffering from severe pancreatitis. While using a Stethoscope to listen to the abdomen, the physician noticed no bowel sounds. After an abdominal CT scan was performed the patient was diagnosed with critical pancreatitis. PROGNOSIS: Feasible complications involve infection in the pancreas and the onset...
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