CC: Abdominal Pain

CC: abdominal pain

HPI: 45 y/o man with h/o of HTN, DM, HLD with a history of abdominal pain that started today. He states his belly has been hurting all day long. He does not know why the pain started but thinks it could be because of something he ate. He had steak last night that was a little undercooked, but he said it tasted good. No one he was eating with got sick. He says he has had belly pain before, but it usually goes away. This time it has not gone away and that is why he came to the ER. The pain starting somewhere in the middle, then it went to his RLQ. He tried to take tums and Tylenol to ease the pain, but it did not help. He did have a couple episodes of vomiting. The first time was a very small amount and he describes it as clear. The second time was a little yellowish. He has been nauseous with a couple episodes of dry heaving since. He has been feeling warm since the pain started, but he does not have a thermometer at home. His wife felt his forehead and said he felt feverish

PMHX: HTN, DM diagnosed 4 years ago with good control PSHX: I and D left calf abscess, R arm fracture s/p ORIF Meds: Metoprolol, Metformin Social: smoked in college for 3 yrs-4-5 cigarettes a day, drinks 2-3 drinks on the weekends when he is out with friends, but usually does not drink if he stays at home, tried marijuana when he was 18, smoked a couple more times in college. ROS: Denies seizure, stroke, cardiopulmonary dz, liver dz, renal dz, hematalogic disorders, alimentary disorders

PE T: 101.3 P: 85 BP: 145/90 SaO2: 98%

Gen: NAD Pul: CTA B Cardiac: RRR Ab: soft, ND, ttp in RLQ, no cross-palpation

Lab: wbc: 15

CT Scan: appendix is visualized with a diameter of 7mm. No contrast is noted in the lumen of the appendix. There is some stranding in the mesentery of the appendix and the cecum. Finding concerning for early acute appendicitis.

CXR: no previous stody to compare with. The lung fields are clear. There is no pulmonary congestion. The borders of the heart are well defined. The aortic in mildly tortuous but mostly unremarkable. Overall, no acute cardiopulmonary disease

A/P: 45 y/o man with h/o of HTN, DM, HLD with a history of abdominal pain that started today. Given the findings of his physical exam and the CT scan, we are worried that the pt may have appendicitis. We will need to talk to him about surgery to remove his appendix. He will need to be consented, admitted to the hospital and started on IV abx. We will need to find a time with the OR for when we can do his surgery.