Age: 42
Date: March 5, 2013
Medical Report
MEDICAL HISTORY:
Patient has a history of gallstones resulting from her diagnosis of cystic fibrosis 3 years ago. Gallstones were removed through ERCP. During the ERCP the doctor did discover that the patient suffered from a pancreatic pseudocyst. An endoscopy was performed for the removal of the pseudocyst. Patient was diagnosed with pancreas divism the day of birth. Patient is currently taking Furosemide due to her diagnosis of hypertension which was diagnosed at the same time as the cystic fibrosis. Patient has high levels of triglyceride and has been diagnosed with hypertriglyceridemia. Mrs. Smith has also been diagnosed with rheumatoid arthritis 6 years ago and is currently prescribed Azathioprine. Patient also has a history of chronic, acute pancreatitis.
SYMPTOMS:
Mrs. Smith came in complaining of acute upper abdominal pain, nausea, and fatigue.
PHYSICAL EXAMINATION RESULTS:
Patient is boarder-line obese so tests were giving to check calcium and lipid levels. Levels in both were higher than normal so the patient was diagnosed with hyperlipidemia, as well as, hypercalcemia. Being that the patient was diagnosed with cystic fibrosis, acute pancreatitis, and hypertriglyceridemia a blood test was administered to check her insulin levels. Her insulin and blood amylace levels were high along with lipase levels. All symptoms are believed to be resulting from the pancreatitis. In order to insure pancreatitis the doctor used a stethoscope to listen to the abdomen for any internal bowel sounds. Afterwards a CT scan was