Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Reason for Visit:
Initial evaluation for suspected pancreatic trauma
Follow-up for diagnosed pancreatic trauma (monitoring response to
treatment, complications)
Evaluation of new or worsening abdominal pain, nausea, vomiting
Chief Complaint:
Abdominal pain (upper left quadrant) – may be severe and constant
Nausea and vomiting
Back pain (radiating to the back) – less common
History of Present Illness:
Mechanism of injury (blunt trauma – common; penetrating trauma –
less common)
Onset, duration, and severity of symptoms.
Presence of associated injuries (e.g., rib fractures, abdominal wall
injuries).
Past Medical History:
Underlying medical conditions (e.g., chronic pancreatitis,
pre-existing diabetes).
Previous surgeries (relevant surgeries on the abdomen or pancreas).
Alcohol use (may worsen outcomes).
Social History:
Not typically relevant for acute pancreatic trauma.
Physical Examination:
General examination: Assess vital signs for signs of shock (hypotension,
tachycardia).
Abdominal examination: Evaluate for tenderness, guarding (involuntary
muscle contraction), distention, or palpable mass.
Focused examination for associated injuries (e.g., chest examination
for rib fractures).
Diagnostic Tests (if indicated):
Imaging studies:
CT scan with contrast: Gold standard imaging for pancreatic trauma,
shows injury details and helps assess for complications.
Magnetic resonance cholangiopancreatography (MRCP): May be helpful
in certain cases to visualize pancreatic ducts and assess for leaks.
Endoscopic retrograde cholangiopancreatography (ERCP): May be used
diagnostically or therapeutically (to place stents in leaking ducts) in
specific situations.
Laboratory tests:
Serum amylase and lipase levels: Elevated levels may suggest
pancreatic injury, but can be nonspecific.
Complete blood count (CBC): May reveal signs of infection (elevated
white blood cell count) in case of complications.
Assessment:
Pancreatic trauma: Based on mechanism of injury, clinical
presentation (symptoms and physical examination findings), and supported by
imaging studies.
Severity of injury: Pancreatic trauma can be classified based on
the degree of pancreatic disruption (grades I-III) and presence of
complications (e.g., duct leaks, hemorrhage).
Presence of associated injuries: Identify and address any other
injuries sustained during the trauma.
Differential Diagnoses:
Consider other conditions that may mimic pancreatic trauma:
Splenic injury (can also cause upper left quadrant pain)
Liver laceration
Kidney injury (if flank pain is present)
Peptic ulcer disease
Plan:
Treatment plan: Depends on the severity of pancreatic trauma,
presence of complications, and the patient’s overall condition. Options
may include:
Non-operative management: Most patients with minor pancreatic
injuries can be managed conservatively with bowel rest, pain medication,
antibiotics, and close monitoring.
Surgical intervention: May be necessary for severe injuries
(grade III), duct leaks, or complications like bleeding. Surgery may
involve debridement (removal of damaged tissue), drainage procedures,
or pancreatic resection (partial or complete removal).
Nutritional support: Enteral or parenteral nutrition may be needed
to provide nutrients while the pancreas heals, promoting healing and
preventing complications.
Pain management: Medications to manage abdominal pain.
Antibiotics: Prophylactic antibiotics may be used to prevent
infection, especially if surgery is performed.
Follow-up: Serial CT scans or MRCP may be necessary to monitor
healing and check for complications. Close clinical monitoring for
signs of infection or worsening symptoms is crucial.