"AOS Review FY2 Von"
Circumstance -- Reviewed at the request of Dr. Smith following an outpatient clinic review to investigate persistent abdominal pain.
Background -- Patient with a history of Stage III colon cancer, diagnosed in 2021. Completed adjuvant chemotherapy with FOLFOX in 2021-2022. Currently in remission.
Presenting complaint -- 68-year-old male with a 2-week history of intermittent, crampy abdominal pain.
History of presenting complaint--
* Pain: Described as intermittent, crampy abdominal pain, located in the lower abdomen.
* Onset: Began approximately two weeks ago, initially mild, now increasing in severity.
* Character: Cramping, colicky.
* Radiation: No radiation.
* Associated Symptoms: Associated with bloating and occasional nausea. No vomiting, fever, or change in bowel habits.
* Timing: Pain occurs in episodes, lasting 30-60 minutes, several times a day.
* Exacerbating Factors: Worsened after meals.
* Severity: Rated 4/10 at its worst.
* No recent changes in medications.
* No recent travel or sick contacts.
Past Medical History --
1. Hypertension, managed with Lisinopril 10mg daily.
2. Hyperlipidemia, managed with Atorvastatin 20mg daily.
Medication History --
1. Lisinopril 10mg, once daily.
2. Atorvastatin 20mg, once daily.
3. Paracetamol 1g, as required for pain.
Social History --
* Non-smoker. Drinks alcohol occasionally, approximately 1-2 units per week. No recreational drug use.
* Lives at home with his wife. Independent in all activities of daily living. WHO performance status 1.
* Retired accountant. No known occupational hazards.
On examination --
* Abdomen: Soft, non-tender on light palpation. Mild tenderness in the lower abdomen on deep palpation. No guarding or rigidity. Bowel sounds present.
* No palpable masses or organomegaly.
* No lymphadenopathy.
Impression --
PLAN
1. Bloods.
2. CT Abdomen and Pelvis with IV contrast to rule out obstruction or recurrence.
3. Review imaging results and discuss with the patient.
4. Follow up in clinic in 2 weeks.
