Date:
Patient:
主诉 (zhǔ訴) (Chief Complaint): Briefly describe the patient’s main reason for presentation, typically involving severe abdominal pain:
Sudden onset, severe, and persistent upper abdominal pain (characteristic but not always present)
May radiate to the back
Described as sharp, stabbing, or burning
History of Present Illness:
Onset and duration of pain
Severity of pain (graded on a scale)
Associated symptoms:
Nausea and vomiting
Fever
Diarrhea
Past medical history (gallstones, alcohol abuse, recent surgery, metabolic disorders)
Medications (current medications, alcohol intake)
Physical Examination:
Vital signs (temperature, heart rate, blood pressure, respiratory rate) – May be elevated with fever and tachycardia.
General examination: Assess for signs of dehydration and distress.
Abdominal examination:
Tenderness to palpation, especially in the epigastrium (upper middle abdomen)
Guarding or rigidity (muscles tense and resist palpation) – indicates severe inflammation
Bowel sounds (may be diminished or absent in severe cases)
Laboratory Findings:
Serum Lipase and Amylase: Elevated levels are suggestive of pancreatitis, but can be elevated in other conditions.
Complete blood count (CBC): May show leukocytosis (high white blood cell count) in severe cases.
Basic metabolic panel (BMP): May show electrolyte imbalances and elevated glucose.
Inflammatory markers: C-reactive protein (CRP) may be elevated in severe cases.
Imaging Studies:
Abdominal X-ray: May show signs of bowel ileus (paralysis).
Abdominal ultrasound: May show gallstones or pancreatic edema.
CT scan with contrast: Preferred imaging study to confirm diagnosis, assess severity, and identify complications.
Assessment:
Summarize the findings and diagnose acute pancreatitis based on clinical presentation, laboratory tests, and imaging studies.
Consider the severity of the attack using scoring systems like the Balthazar CT severity index or the Revised Atlanta Classification.
Identify the suspected cause of pancreatitis (e.g., gallstones, alcohol abuse, medications).
Plan:
Fluid resuscitation: Intravenous fluids are essential to correct dehydration and electrolyte imbalances.
Pain management: Administer pain medication to improve comfort.
Dietary management: NPO (nothing by mouth) initially, then progress to a clear liquid diet as tolerated.
Nutritional support: Enteral or parenteral nutrition may be needed for prolonged cases.
Address the underlying cause:
Cholecystectomy (gallbladder removal) for gallstone pancreatitis
Stopping alcohol intake
Discontinuing causative medications
Consultations:
Gastroenterology
Surgery (if indicated for complications)
Progress Notes:
Document daily assessments including vital signs, pain level, nausea/vomiting, abdominal exam findings, and urine output.
Note any changes in laboratory results and imaging studies (if repeated).
Update the plan as needed based on the patient’s progress and response to treatment.
Monitor for complications (sepsis, pancreatic necrosis, organ failure).
Discharge Instructions (for patients with improving symptoms):
Follow-up appointments with a gastroenterologist to monitor recovery.
Dietary recommendations (low-fat diet)
Alcohol abstinence (if applicable)
Pain management plan
Disclaimer: This template is for informational purposes only and should not be used as a substitute for professional medical advice. Early diagnosis and treatment are crucial to improve outcomes and prevent complications.