Comprehensive Acute Pancreatitis Case Study

This is not a real patient chart. The names and data have been created.

Patient Chart

Patient Name: Maria Elizabeth Turner
Date of Birth: 09/22/1985
Age: 39
Gender: Female
Medical Record Number: 20250308
Date of Admission: 03/08/2025
Primary Care Provider: Dr. Robert Harris

Chief Complaint (CC)

"I’ve had severe upper abdominal pain for the past 2 days, and I feel nauseous and can’t eat."

History of Present Illness (HPI)

Maria Turner is a 39-year-old female presenting with acute onset of severe epigastric pain that began 2 days ago. The pain is described as sharp and constant, radiating to the back. She rates the pain as 8/10 in severity. The pain worsens after eating and is not relieved by over-the-counter antacids. She reports associated symptoms of nausea, vomiting, and lack of appetite. She denies any fever, chills, or diarrhea.

The patient has a history of alcohol use, drinking approximately 4-5 alcoholic beverages daily for the past 15 years. She also has a history of gallstones diagnosed two years ago, which were managed conservatively.

Past Medical History (PMH)

• Chronic Alcohol Use – 4-5 alcoholic drinks per day for the past 15 years
• Gallstones – diagnosed 2 years ago, managed conservatively
• Hypertension – diagnosed 8 years ago, controlled with Lisinopril
• Hyperlipidemia – diagnosed 5 years ago, controlled with atorvastatin

Surgeries & Procedures

• Cholecystectomy (laparoscopic) 2 years ago due to gallstones

Allergies

• No known drug allergies

Medications

• Lisinopril 10 mg daily
• Atorvastatin 20 mg nightly
• Multivitamins daily

Family History (FH)

• Father: Alive, 62, with hypertension and type 2 diabetes
• Mother: Alive, 60, with hyperlipidemia
• Brother: Alive, 36, healthy

Social History (SH)

• Smoking: Former smoker, quit 5 years ago (10 pack-years)
• Alcohol: Drinks 4-5 drinks daily
• Drug Use: Denies illicit drug use
• Occupation: Office manager
• Living Situation: Lives with her husband and two children

Review of Systems (ROS)

• General: Fatigue, lack of appetite, weight loss (unintentional)
• Cardiovascular: No chest pain, occasional palpitations
• Respiratory: No shortness of breath or cough
• Gastrointestinal: Severe upper abdominal pain, nausea, vomiting, no diarrhea
• Neurological: No focal deficits or dizziness

Physical Assessment Findings

Vital Signs:

• Temperature: 100.1°F (37.8°C)
• Heart Rate: 110 bpm, regular
• Respiratory Rate: 18 breaths/min
• Blood Pressure: 128/78 mmHg
• Oxygen Saturation: 98% on room air
• Height: 6'2"
• Weight: 178 lbs.

General Appearance: Mildly distressed, clutching abdomen in discomfort
Cardiovascular: Tachycardic, regular rate and rhythm, no murmurs
Abdomen: Tenderness in the epigastric region, worse with palpation, no rebound tenderness or guarding, bowel sounds present
Skin: Mild jaundice noted
Neurological: Alert, oriented, no focal deficits

Laboratory Results

Basic Metabolic Panel (BMP)

Complete Blood Count (CBC)

Liver Function Tests (LFTs)

Pancreatic Enzymes

Coagulation Profile

Imaging and Diagnostics

Abdominal Ultrasound

Findings:

• Enlarged pancreas with increased echogenicity, consistent with acute pancreatitis.
• No gallstones or biliary obstruction seen.
• Mild peripancreatic fluid accumulation.

CT Abdomen (with Contrast)

Findings:

• Acute pancreatitis with enlarged pancreas, diffuse pancreatic inflammation, and peripancreatic fluid collection.
• No signs of pancreatic necrosis or pseudocyst formation.
• No biliary obstruction or stones.