Cyst and pseudocyst of pancreas Acute kidney failure unspecified Chronic systolic heart failure Unspecified pleural effusion Congestive heart failure unspecified Diabetes mellitus without mention of complication type II or unspecified type not stated as uncontrolled Coronary atherosclerosis of unspecified type of vessel native or graft Unspecified essential hypertension Aortocoronary bypass status Long-term (current) use of aspirin
 
Name:  ___                Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 
Allergies: 
Penicillins / Vancomycin / Levofloxacin / Unasyn / Tigecycline / 
Meropenem / Metoprolol
 
Attending: ___.
 
Chief Complaint:
Nausea; abdominal pain
 
Major Surgical or Invasive Procedure:
none

 
History of Present Illness:
___ gentleman with DM, HTN, CAD and recent FICU admission for 
necrotizing pancreatitis and pseudocyst is now admitted to the 
FICU for ___ drainage of enlarging pseudocyst.

He was admitted from ___ for necrotizing pancreatitis that 
began in ___ and was complicated by shock, bacteremia, VAP, 
hypoxic respiratory failure requiring intubation and eventually 
tracheostomy.  He had been discharged to rehab, and 2 days later 
his trach was removed and he was breathing fine on RA during the 
day, 1L NC st night.  He awoke on the morning of presentation 
with nausea and abdominal pain, so he presented to the ED.  It 
is epigastric, moving horizontally but not to the back, and is a 
deep pain.  His pain is very similar to prior pancreatitis pain, 
but the nausea is new.  No vomiting, no fever/chills.

In the ED, initial vs were: T 97.1, HR 100, BP 122/62, RR 14, 
SaO2100%RA
By the time of presentation his abdominal pain had subsided, and 
his exam was benign.  He had a mild leukocytosis (11.1) and 
amylase was 112.  His Cr was 1.6 (baseline 1.3) so he was 
hydrated with 1200cc IVF and Mucomyst (slowly, as patient has 
history of CHF), then sent for abdomen CT with contrast.  This 
showed enlarging pancreatic pseudocyst, pelvic fluid collection 
smaller than on previous imaging, new small fluid collection 
anterior to pancreas as well as new small pseudocyst in 
pancreatic head.  Upon returning from CT, he complained of ___ 
abdominal pain and he was given a total of 8mg IV morphine, and 
Zofran.
He is tachycardic, but his blood pressures have been stable and 
he has no fever.  Surgery is aware of the patient; they feel 
that there is no need for surgical intervention at this time.  
He is being admitted to the FICU with plans for ___ drainage of 
the pseudocyst.
  
On the floor, the patient is without complaints.  He has no 
abdominal pain.  Not nauseous currently, but has no appetite.  
Does have an itchy rash that he has had since his last 
hospitalization that has been treated at rehab with antifungal 
powder and Benadryl.
  
Review of systems:  
(+) Per HPI (nausea, abdominal pain, rash)
(-) Denies fever, chills. Denies cough, shortness of breath, or 
wheezing. Denies chest pain, chest pressure, palpitations, or 
weakness. Denies vomiting, diarrhea, constipation, or changes in 
bowel habits. Denies dysuria, frequency, or urgency. Denies 
arthralgias or myalgias.
 
Past Medical History:
1. Necrotizing pancreatitis (___) 
- complicated by Enterococcus bacteremia, septic shock, hypoxic 
respiratory failure requiring intubation/trach (which was 
removed at rehab)
2. CABG ___
3. DM II with neuropathy  
4. CHF (EF 35-40% ___ TTE)  
5. Hypertension 
6. Hyperlipidemia  
7. MSSA epidural abscess s/p laminectomy - ___

 
Social History:
___
Family History:
Dad passed away from complications of CAD (MI in ___ and CHF. 
Mother had an MI in her ___. Sister with obesity, DM.

 
Physical Exam:
Vitals: T:96.9 BP:119/76 P:102 R: 17 O2:98%2L NC  
General: Alert, oriented x3, no acute distress  
HEENT: Sclera anicteric, MMM, oropharynx clear  
Neck: supple, JVP not elevated, no LAD  
Lungs: Clear to auscultation bilaterally, no wheezes, rales, 
ronchi  
CV: Tachycardic, normal S1 and S2, regular, no murmurs
Abdomen: obese but nondistended; bowel sounds present; soft; 
non-tender; tenderness to very deep palpation of epigastrium; no 
rebound tenderness or guarding
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or 
edema  
Skin: rash on back near costal angles bilaterally - raised 
erythematous plaques with scale and satellite lesions 

 
Pertinent Results:
___ 01:40PM   WBC-11.1* RBC-4.02*# HGB-11.7*# HCT-34.9*# 
MCV-87 MCH-29.0 MCHC-33.4 RDW-17.7*
___ 01:40PM   NEUTS-82.9* LYMPHS-11.5* MONOS-3.7 EOS-1.4 
BASOS-0.5
___ 01:40PM   PLT COUNT-372

___ 01:40PM   ___ PTT-22.8 ___

___ 01:40PM   ALT(SGPT)-13 AST(SGOT)-14 ALK PHOS-74 
AMYLASE-112* TOT BILI-0.4
___ 01:40PM   LIPASE-40

___ 01:40PM   GLUCOSE-119* UREA N-39* CREAT-1.6* SODIUM-137 
POTASSIUM-3.8 CHLORIDE-94* TOTAL CO2-31 ANION GAP-16

___ 01:45PM   LACTATE-1.1

___ UA - rare bacteria
___ Urine Cx - pending

___ CT Abdomen/Pelvis with Contrast:
IMPRESSION: 
1. The large pancreatic body pseudocyst has continued to enlarge 
further 
across multiple prior studies. There is now possibly development 
of a 
satellite pseudocyst and/or adjacent small peripancreatic fluid 
collections as detailed above. 
2. There is a relatively eccentric but traumatic wall thickening 
of the 
adjoining gastric body, pylorus, and proximal duodenum. This may 
be reactiv
in nature if pancreatic enzymes continue to leach or also may 
represent a 
coincident gastritis. Correlate clinically. This may account for 
an acute 
pain as described. Not mentioned above, there may be a minimal 
amount of 
fluid tracking within the gastrohepatic ligament. 
3. The relatively wide U-shaped pelvic collection previously 
described has 
decreased in size from the prior exam. The previously noted 
pigtail 
percutaneous drain is no longer present. 
4. Persistent right pleural effusion with bibasilar atelectasis. 

 
Brief Hospital Course:
1. Pancreatic pseudocyst.  CT imaging showed enlarging 
pancreatic pseudocyst.  GI and surgery (Dr. ___ discussed 
options for drainage and initially determined that the best 
course was endoscopic drainage. However, during the 
hospitalization his pain improved and he remained stable, with 
no laboratory evidence of worsened pancreatitis.  After 
discussion with patient, it was agreed to postpone the drainage, 
given risks involved, and reassess in about ___ weeks.  
Outpatient follow-up with CT, followed by appointment in 
Gastroenterology, was arranged.   

2. Acute renal failure.  Baseline is 1.3.  It was felt that 
acute renal failure was  likely prerenal on admission.   He 
improved to baseline with hyudration.  

3. Pleural effusion.  Previously attributed to 
trans-diaphragmatic ascites.  Not felt to represent 
CHF/cardiogenic volume overload.
 
4. Depression-- contniued on SSRI

On ___ he was deemed appropriate for transfer to a rehab 
facility and this was arranged.  
 
Medications on Admission:
-Aspirin 325 mg PO/NG DAILY  
-Diltiazem 120 mg PO/NG QID 
-Humalog Sliding Scale & Fixed Dose Lantus
-Acetaminophen 325-650 mg PO/NG Q4H:PRN pain 
-Miconazole Powder 2% 1 Appl TP QID:PRN to folds
-Citalopram Hydrobromide 10 mg PO/NG DAILY  
-Multivitamins W/minerals 1 TAB PO DAILY  
-Docusate Sodium 100 mg PO BID 
-Pancrelipase 5000 2 CAP PO TID W/MEALS
-Famotidine 20 mg PO/NG Q24H  
-Heparin 5000 UNIT SC TID  
 
Discharge Medications:
1. Diltiazem HCl 120 mg Tablet Sig: One (1) Tablet PO four times 
a day.  
2. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).  
3. Multivitamin,Tx-Minerals     Tablet Sig: One (1) Tablet PO 
DAILY (Daily).  
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 
times a day).  
5. Lipase-Protease-Amylase 5,000-17,000 -27,000 unit Capsule, 
Delayed Release(E.C.) Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A 
DAY WITH MEALS).  
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 
hours).  
7. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical 
QID (4 times a day) as needed for itching.  
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID 
(4 times a day) as needed for to folds.  
9. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at 
bedtime).  
10. insulin per previous regimen

 
Discharge Disposition:
Extended Care
 
Facility:
___
 
Discharge Diagnosis:
Pancreatic pseudocyst

 
Discharge Condition:
Fevers, worsened abdominal pain, nausea/vomiting

 
Discharge Instructions:
  
You were admitted with abdominal pain and found to have an 
enlarging pseudocyst.  Initial plan was to drain this by a 
percutaneous (needle) procedure, but over the course of 
hospitalization your pain has improved and you have remained 
clinically stable, so the decision was made to postpone the 
procedure and reassess in approximately ___ days
 
Followup Instructions:
___

{'nausea': ['Cyst and pseudocyst of pancreas'], 'abdominal pain': ['Cyst and pseudocyst of pancreas'], 'tachycardic': [], 'leukocytosis': [], 'itchy rash': [], 'fever/chills': [], 'cough/shortness of breath/wheezing': [], 'chest pain/chest pressure/palpitations/weakness': [], 'vomiting': [], 'diarrhea/constipation(changes in bowel habits)': [], 'dysuria/frequency/urgency': [], 'arthralgias/myalgias': []}