Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Visit]
主訴 (zhǔ訴) Chief Complaint:
Document the patient’s main presenting concerns. This may include:
Abdominal pain (often upper left quadrant) – may be constant or episodic, radiating to the back
Nausea and vomiting
Fever (may be present)
Weight loss (in chronic cases)
现病史 (xiàn bìng shǐ) History of Present Illness:
Onset and duration of symptoms.
Severity and character of abdominal pain (sharp, dull, achy).
Associated symptoms (nausea, vomiting, fever).
Recent history of alcohol abuse, gallstones, or pancreatitis.
既往史 (jì wàng shǐ) Past Medical History:
History of pancreatitis (acute or chronic)
Gallstone disease
Alcohol abuse
Hyperlipidemia
Prior surgeries (especially abdominal)
家族史 (jiā zú shǐ) Family History:
Family history of pancreatitis (uncommon)
社会史 (shè huì shǐ) Social History:
Alcohol consumption
Smoking history
Occupation (certain occupations have higher risk factors for pancreatitis)
查体 (chá tǐ) Physical Examination:
Vital signs (may be normal or show signs of inflammation – fever, tachycardia)
General examination: assess for signs of dehydration, jaundice (if involving bile duct).
Abdominal examination:
Tenderness in the upper left quadrant (common)
Guarding or rigidity (may suggest severe inflammation)
Mass (may be present in some cases of pseudocyst)
Bowel sounds (may be hypoactive in severe inflammation)
辅助检查 (fú zhu zhuān chá) Laboratory Tests:
Complete blood count (CBC):
May show elevated white blood cells (leukocytosis) indicating inflammation.
Serum lipase and amylase:
Elevated levels are suggestive of pancreatitis, but not specific.
Liver function tests:
May be abnormal if involving the bile duct or with significant inflammation.
Inflammatory markers (CRP, ESR):
May be elevated in acute pancreatitis.
影像学检查 (yǐng xiàng xué jiǎn chá) Imaging Studies:
Abdominal ultrasound:
Initial imaging modality to assess the pancreas, identify gallstones, and detect fluid collections.
CT scan of the abdomen with contrast:
More detailed imaging to define the characteristics of the fluid collection (acute collection, pseudocyst, necrosis).
MRI with magnetic cholangiopancreatography (MRCP):
May be helpful in some cases to visualize the pancreatic duct and biliary tree.
诊断 (zhěn duàn) Diagnosis:
Inflammatory pancreatic fluid collection.
Specify the type of collection based on imaging findings (e.g., acute pancreatic necrosis, pancreatic pseudocyst).
If possible, identify the underlying cause (e.g., alcoholic pancreatitis, gallstone pancreatitis).
分期 (fēn qī) Staging (optional):
Some classification systems categorize acute pancreatitis based on severity (mild, moderate, severe).
治疗方案 (zhì liáo fāng àn) Treatment Plan:
Treatment depends on the severity of the condition and the type of fluid collection.
Supportive measures for all cases include:
Intravenous fluids for hydration
Pain management
NPO (nothing by mouth) initially, followed by gradual reintroduction of diet
Antibiotics (if infection is present)
Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy (removal of a stone obstructing the pancreatic duct) – for gallstone pancreatitis
Percutaneous drainage (placing a drain to remove fluid) – for symptomatic pseudocysts
Surgery (rarely needed, for severe complications or failed interventions)
预后 (yù hòu) Prognosis:
Discuss the outlook based on the severity of the condition, underlying cause, and response to treatment.
Acute pancreatitis often resolves with supportive care.
Pseudocysts may require intervention and have a risk of recurrence.
Chronic pancreatitis can lead to complications and may require ongoing management.
健康指导 (jiàn kāng zhǐ dào) Patient Education:
Importance of following dietary recommendations (low-fat diet in some cases).
Alcohol cessation (if applicable)
Smoking