Subjective (Information from parents/guardians):
Date of visit
Reason for visit (initial presentation, follow-up)
History of present illness:
Onset and severity of abdominal pain (location, character, radiation)
Nausea and vomiting
Decreased appetite
Fever
Recent illness or infections
Medications (including over-the-counter)
Alcohol use (if applicable for teenager)
Family history of pancreatitis
Objective
Vital signs (temperature, heart rate, blood pressure)
Physical exam:
General appearance (illness, pain)
Abdominal examination (tenderness, guarding, distention)
Signs of dehydration (dry mucous membranes, poor skin turgor)
Labs:
Serum lipase and amylase (elevated levels suggestive of pancreatitis)
Electrolytes (may be deranged due to dehydration)
Complete blood count (CBC) with differential (may show elevated white blood cells if infection suspected)
Liver function tests (may be abnormal in some cases)
Imaging (may be ordered depending on severity):
Abdominal ultrasound (initial imaging to assess pancreas and exclude other causes)
Abdominal CT scan (if ultrasound inconclusive or severe pancreatitis suspected)
Assessment
Pediatric pancreatitis:
Severity (mild, moderate, severe) based on Atlanta criteria (consider scoring system if applicable)
Likely etiology (idiopathic, post-infectious, medication-induced, etc.)
Differential diagnoses (appendicitis, peptic ulcer disease, gastroenteritis)
Plan
Management will depend on severity:
Supportive care:
Intravenous fluids for hydration and electrolyte replacement
Pain management (medications)
NPO (nothing by mouth) initially, then gradual transition to clear liquids and a low-fat diet as tolerated
Consider nasogastric suction for persistent vomiting
Identify and address underlying cause (if possible)
Consultation with a pediatric gastroenterologist (if needed)
Monitoring
Vital signs and pain assessment
Electrolytes and hydration status
Serial lipase and amylase levels to monitor improvement
Imaging follow-up if needed
Prognosis
Discuss the expected course of illness and potential complications:
Most cases of pediatric pancreatitis are mild and resolve within a few days
Potential complications (sepsis, pancreatic pseudocyst formation)
Follow-up
Schedule for next appointment:
Close monitoring initially, then follow-up based on clinical course
Dietary counseling
Note: This is a template and may need to be modified based on the individual patient’s presentation and severity of pancreatitis.
Disclaimer: This information is for educational purposes only and should not be interpreted as medical advice. Please consult with a qualified healthcare professional for diagnosis and treatment of pediatric pancreatitis.