CC: I have an abdominal pain x 1 week

Subjective:

51 years old male with PMHx antiphospholipid syndrome, hx DVT/PE, seizure, colonic perforation, abdominal wound infection, presents with a chief complaint of low abdominal pain. According to the patient, the pain began approximately 7 days prior in the area just above this umbilicus and radiated laterally to his right lower quadrant. He describes the pain as intermittent, dull discomfort, rates as 3/10 at beginning, but he did not pay much attention, or take any medication at that time. Patient states about 3 to 4 days later, his abdominal pain became frequent, crampy, and sharp in nature. He states the pain is mild relieved when he is laying down and worsened with movement. Pt reports he took Miralax yesterday for constipation but the pain worsened and became more constant until he could no longer tolerate it which reminded him of a colon perforation in the past which is when he decided to come into the ER for evaluation. He also complains nausea, chill, lower back pain associate with his abdominal pain. Pt denies fever, headache, lightheadedness, dizziness, vomiting, chest pain, palpitations, shortness of breath, blood/mucous in BM, change in urinary habits, calf tenderness.

Objectives:

Allergies: NKDA

Current Medication:

• Amlodipine 5 mg tablet PO once daily
• Lacosamide 50 mg tablet PO once daily
• Losartan 100 mg tablet PO once daily
• Rivaroxaban 10 mg tablet PO once daily

Vitals:

• BP: 161/99, lying position, right arm
• HR: 116 bpm, tachycardia
• RR: 20 breaths per minute, regular
• O2 Sat: 99%, RA
• T: 97 oral
• Ht: 71 in Wt: 258 lbs     BMI: 36.07 kg/m2

Physical Exam

• Gen – Well nourished, well developed male resting in bed, no apparent distress
• ENT – NC/AT, no JVD noted
• Thorax – Symmetric, no retractions
• Lung – CTA b/l, no rhonchi, rales or wheezes noted
• CV – S1S2 distinct, no M/R/G, RRR. No carotid bruits
• Abdomen – Soft, mild distended, generalized tenderness to palpation worse on right side of abdomen and over lower quadrants, positive rebound tenderness, positive Rovsing’s sign, no masses to palpation, no hepatosplenomegaly.
• Extremities – Legs no cyanosis, tender, or edema, radial/DP pulses +2 bilaterally
• Neuro – A&O x 3, no gross motor or sensory deficits, CN II-XII grossly intact

Labs:

Lab	10/04/2020 0459
WBC	12.31 (H)
HGB	16.1
HEMATO	45.4
PLTORD	225
Neutrophil %	90. 6 (H)
Neutrophil (absolute)	11.1 (H)
Lymphocyte %	3.5 (L)
Lymphocyte (absolute)	0.4 (L)

 

Lab	10/04/202 0638
NA	137
K	3.4 (Low)
CL	100
CO2	26
BUN	12
CREATININE	1.1
GLU	134 (H)
CALCIUM	9.7

 

Lipase	12
Lactic Acid Level	2.8 (H)
PT	12.6 (H)
INR	1.2 (H)
PTT	36.2 (H)

CT abdomen and pelvic on 10/04 shows that

IMPRESSION: There is inflammatory stranding is seen within the right lower quadrant of the abdomen with an area of increased density worrisome for acute, perforated appendicitis. There is a developing fluid collection within this area. This is likely not drainable. The visualized abdominal aorta and branch vasculature appears patent. There are multiple collateral vessels seen within the anterior abdominal wall and abdomen which may be secondary to occlusion or thrombosis within the IVC. The spleen is enlarged.

Assessment

51 years old male with PMHx antiphospholipid syndrome, hx DVT/PE, seizure, colonic perforation, abdominal wound infection, presents with a chief complaint of low abdominal pain. History and physical findings consistent with perforated appendicitis.

 

Plan

• Order EKG, CT of abdomen and pelvis
• Admit to General Surgery
• NPO, IVF while NPO
• Pain control, prn – avoid narcotics as able
• Zosyn
• Plan for laparoscopic possible open appendectomy