Cyst and pseudocyst of pancreas Chronic pancreatitis Congestive heart failure unspecified Coronary atherosclerosis of unspecified type of vessel native or graft Unspecified essential hypertension Diabetes with neurological manifestations type II or unspecified type not stated as uncontrolled Polyneuropathy in diabetes Other and unspecified hyperlipidemia Aortocoronary bypass status
 
Name:  ___                Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: SURGERY
 
Allergies: 
Penicillins / Vancomycin / Levofloxacin / Unasyn / Tigecycline / 
Meropenem / Metoprolol
 
Attending: ___.
 
Chief Complaint:
Pancreatic pseudocyst
 
Major Surgical or Invasive Procedure:
___: EUS for drainage attempt

 
History of Present Illness:
Mr. ___ is a ___ year old male with recent history of 
necrotizing pancreatitis and an enlarging pancreatic pseudocyst. 
Patient was admitted from ___ for necrotizing pancreatitis 
complicated by shock, bacteremia, ventilator associated 
pneumonia, and hypoxic respiratory failure requiring intubation 
and eventually tracheostomy. He was readmitted from rehab on
___ with complaints of worsened abdominal pain and nausea 
and was found to have enlargement of his pseudocyst to 8.8 x 6.8 
cm from 7.7 x 6.2 cm. Endoscopic and open surgical drainage of 
the pseudocyst were discussed with the patient with plans for 
endoscopic cyst-gastrostomy. However, his pain improved with  no 
laboratory evidence of worsened pancreatitis and it was decided 
to postpone the drainage and reassess in 2 weeks. Repeat CT on 
___ demonstrated stable appearance of the largest portion of 
pancreatic pseudocyst with a new locule at itssuperior aspect 
measuring 4.8 x 2.8 cm. Patient presented on ___ for 
endoscopic cyst-gastrostomy. EUS revealed a large
blood vessel, possibly a splenic artery pseudoaneurysm, between 
the wall of the stomach and the pseudocyst and a moderate amount 
of debris within the cyst. Endo cyst-gastrostomy was deemed 
unsafe due to risk of infection and vascular injury and the 
procedure was aborted. Post-procedure, patient was complaining 
of
abdominal pain, requiring IV pain medication for relief.
Pancreaticobiliary surgery was reconsulted for possible open 
pseudocyst drainage. Patient's symptoms of pain and food 
intolerance due to fullness and nausea have been unchanged 
throughout this period, although improved with eating smaller 
portions.

 
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-98.6 HR-126 BP-130/82 RR-20 O2 Sat-96% RA
Gen: Well appearing, NAD
CV:RRR, Nl S1, S2 
Resp: CTAB, no distress
Abd: Soft, NT, ND, multiple ecchymoses (heparin related)
Ext: No edema, scars on bilateral lower extremities from vein
harvests

 
Pertinent Results:
___ 09:00AM BLOOD WBC-6.2 RBC-3.79* Hgb-10.9* Hct-34.0* 
MCV-90 MCH-28.9 MCHC-32.2 RDW-16.8* Plt ___

EUS (___):
- Pseudocyst was visualized and adjacent to the stomach. 
- Large blood vessel, possibly a splenic artery pseudoaneurysm,
was visualized between the wall of the stomach and the
pseudocyst. Additionally, a moderate amount of debris was seen
within the cyst. Endo cyst-gastrostomy not deemed safe.
- Normal upper eus to second part of the duodenum 

 
Brief Hospital Course:
The patient with history of chronic pancreatitis and large 
pancreatic pseudocyst was admitted to the General Surgical 
Service for observation after attempted EUS cystgastrostomy. The 
procedure was aborted s/t possibly a splenic artery 
pseudoaneurysm, between the wall of the stomach and the 
pseudocyst and a moderate amount of debris within the cyst and 
high risk for vascular injury or infection. Patient was admitted 
overnight for pain control. On HD # 1, patient's diet was 
advanced to regular, pain was well controlled. Patient was 
evaluated by Dr. ___ scheduled for elective open 
cystgastrostomy or cystojejunostomy on next week. Patient was 
discharged back in Rehab in stable condition. 

.

At the time of discharge, the patient was doing well, afebrile 
with stable vital signs. The patient was tolerating a regular 
diabetic diet, ambulating, voiding without assistance, and pain 
was well controlled. The patient received discharge teaching and 
follow-up instructions with understanding verbalized and 
agreement with the discharge plan.

 
Medications on Admission:
1. Diltiazem HCl 120 mg po q6h
2. Famotidine 20 mg Tablet daily
3. Vicodin 5 mg-500 mg Tablet po TID prn pain 
4. Insulin Glargine 25 units SC at bedtimenr 
5. Pancrelipase 5000- 2 Capsule(s) po TID with meals 
6. Trazodone 50 mg Tablet po HS 
7. Tylenol, Bisacodyl, Colace, Milk of Magnesia,Multivitamin 

 
Discharge Medications:
1. Diltiazem HCl 120 mg Tablet Sig: One (1) Tablet PO every six 
(6) hours.  
2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 
 
3. Hydrocodone-Acetaminophen ___ mg Tablet Sig: One (1) Tablet 
PO Q8H (every 8 hours) as needed for pain.  
4. 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).  
5. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) 
as needed for sleep.  
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 
times a day).  
7. Multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily). 
 
8. Insulin Glargine 100 unit/mL (3 mL) Insulin Pen Sig: Twenty 
Five (25) units Subcutaneous at bedtime.  
9. Insulin Regular Human 100 unit/mL (3 mL) Insulin Pen Sig: 
___ units Subcutaneous before meals and bedtime.  

 
Discharge Disposition:
Extended Care
 
Facility:
___
 
Discharge Diagnosis:
1. Chronic pancreatitis
2. pancreatic pseudocyst

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker 
or cane).

 
Discharge Instructions:
Weigh yourself every morning, call MD if weight goes up more 
than 3 lbs.
Please resume all regular home medications , unless specifically 
advised not to take a particular medication.  Also, please take 
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times 
per day, and drink adequate amounts of fluids.  Avoid lifting 
weights greater than ___ lbs until you follow-up with your 
surgeon, who will instruct you further regarding activity 
restrictions.
Avoid driving or operating heavy machinery while taking pain 
medications.
Please follow-up with your surgeon and Primary Care Provider 
(PCP) as advised.

 
Followup Instructions:
___

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