DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
ADMISSION DIAGNOSIS: Pancreatitis.
DISCHARGE DIAGNOSES:
1. Pancreatitis, resolving.
2. Allergic rhinitis.
3. Headache.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic female with no significant past medical history other than some mild nonspecific headache for the last six months, who was transferred for evaluation of pancreatitis and possible appendicitis. As per the family, the patient was in her usual state of health until approximately 7 in the evening, one day prior to admission, when she developed epigastric chest-like pain.
At that time, she felt like she could not breathe and turned pale and after throwing up in the emergency department had some relief. During her initial workup in the emergency department, she had elevated amylase at 750 and elevated lipase at 520. Alkaline phosphatase was also noted to be elevated at 198, and AST and ALT were normal. On report from parents, a CT was performed where there was a question of appendicitis, but after being reviewed by the pediatric radiologist, it was felt that the CT looked normal.
The patient did undergo an ultrasound upon arrival to this facility, right upper quadrant ultrasound, which was read as normal. There was also some question of debris in her bladder based on the review of the CT, so urinalysis was performed, which also appeared negative without any signs of infection. The patient had her amylase and lipase followed throughout her hospitalization with her amylase at the time of her arrival here being 210 and on the day of discharge down to 146. Her lipase had remained normal throughout her hospitalization in addition to her alkaline phosphatase, AST and ALT.
The patient did report some frontal-like headache during her hospitalization that was treated with some Tylenol and Toradol. Parents reported strong family history of allergic rhinitis, and the patient does have what appears to be allergic rhinitis symptoms. We recommended to the mother that we treat this appropriately and see if her headaches do resolve.
In addition to this, the patient did not continue with antibiotics during her hospitalization here; although, she did receive her first dose at the outside facility. She remained afebrile without any abdominal pain and tolerated starting of her low-fat diet well without any emesis or abdominal pain.
PHYSICAL EXAMINATION: On the day of discharge, the patient’s temperature is afebrile with stable vital signs. General: The patient is sitting up in bed, playing on her computer, in no acute distress. HEENT: Normocephalic and atraumatic. Moist mucous membranes. No sinus tenderness. Nasal mucosa slightly erythematous. Conjunctivae and sclerae clear. Lungs: Clear to auscultation bilaterally. Good air exchange. Cardiovascular: Regular rate and rhythm without murmur, 2+ pulses. Capillary refill less than 2 seconds. Abdomen: The patient does have some right lower quadrant mild tenderness with deep palpation but no rebound tenderness. No guarding. She does have some mild left upper quadrant tenderness. No hepatosplenomegaly.
ASSESSMENT AND PLAN: The patient is a (XX)-year-old female with acute episode of pancreatitis, which appears to be resolving. In addition to this, she appears to have allergic rhinitis that is untreated and could be contributing to her frequent headaches. We will discharge her home today on Flonase, loratadine and have her follow up with her labs in approximately a week and have her discuss these results with her primary care physician. We will also have her continue with low-fat diet until she is cleared by her primary care physician.
