Ophthalmology Case Study

HISTORY
 Patient is a 53-year-old male who was seen the day prior in my clinic by _________ for some reflux, nausea, and abdominal cramping.  He underwent a KUB, given some Levsin and Nexium.  He said the pain has gotten probably little worse but now he is having recurrent vomiting.  He says he is vomiting about every hour despite the Phenergan.  Has been having fever.  He said he had chills and sweats last night but he did not measure his temperature.  When I saw him today, he walks in gently.  This guy hardly ever comes to clinic except for routine visits for his blood pressure and he is hurting, he is holding his right side walking, getting to lie down.  On examining, he has positive bowel sounds but very hypoactive.  He is tender in his right lower quadrant.  Really no rebound.  Palpating those sides does not hurt and all of his stomach does not hurt and he said he is not sure what he has got.

He had a CBC, his white count of 10.5 with left shift but everything else is normal.  He had a CT scan of his abdomen and pelvis, CT scan reported appendicitis which was consistent with the clinical diagnosis.

CURRENT MEDICATIONS

1.            Zocor 40 milligrams a day.

2.            Nexium 40 milligrams a day.

3.            He is on Toprol-XL 50 milligrams a day .

4.            Norvasc 5 milligrams a day.

PAST MEDICAL HISTORY

He has had hypertension for about 13 years.  He has had hyperlipidemia and he is on the Zocor for about the last 3 to 4 years.  He also has GERD.  Past medical history otherwise is pretty much unremarkable.  ______ and really do not have a knowledge of what is going on. 

FAMILY HISTORY

His father had MI at 52, grandfather at 55.

SOCIAL HISTORY

He has 30 to 40-pack-year history of smoking.  He likes to drink beer.  He works, married, with step child.

OBJECTIVE

VITAL SIGNS:  When I saw, patient's blood pressure was elevated but he was in lot of pain.  His blood pressure was 156/102, pulse 68.

ENT EXAM:  His oropharynx is somewhat dry.  He says he is not been able to keep a whole lot down except for water.  His TMs are clear.

CHEST:  He has bilateral breath sounds and rhonchi.

CARDIAC EXAM:  Revealed a regular rate and rhythm.

ABDOMEN:  He has positive bowel sounds.  He is tender in his right lower quadrant as mentioned above.

RECTAL EXAM:  He had good tone.  His guaiac negative.  He did have some loose stools but he had been taking laxatives, thinking he was constipated but the stool is light brown.  Prostate is not enlarged.

EXTREMITIES:  No edema. 

ASSESSMENT

1.            Acute appendicitis.

2.            Hypertension.

3.            Gastroesophageal reflux disease.

4.            Hyperlipidemia.

5.            Tobacco abuse.

PLAN

To admit to the hospital where I consulted to __________.  He will need emergency surgery, this was explained to the patient, to prevent rupture.  He understands this, I explained risks and benefits.  He said if it ruptures that all the poison will go in my stomach from the appendix, I said that is exactly right, so he said I will get this thing done.  We are setting this up.