Surgical Review

Patient Information: - John Doe - 45 - Male - 123456 Presenting Complaint: - Abdominal pain and bloating for the past two weeks. History of Presenting Complaint: - The patient reports a gradual onset of abdominal pain, which has been persistent and worsening over the last two weeks. The pain is described as a dull ache, primarily in the lower abdomen, and is associated with bloating and occasional nausea. Past Medical History: - Appendectomy in 2010, hypertension. Medications: - Lisinopril 10 mg daily, multivitamin. Allergies: - Penicillin (rash). Family History: - Father had colon cancer at age 60. Social History: - Works as an accountant, non-smoker, drinks alcohol socially, no recreational drug use. Review of Systems: - Positive for abdominal discomfort and bloating. Negative for fever, weight loss, or changes in bowel habits. Physical Examination: - Vital signs: BP 130/85, HR 78, Temp 98.6°F. General appearance: alert and oriented. Abdominal examination: mild tenderness in the lower quadrants, no rebound tenderness, normal bowel sounds. Investigations: - Ordered abdominal ultrasound and complete blood count. Impression: - Possible diverticulitis or other gastrointestinal pathology. Plan: - Start on a clear liquid diet, prescribe antibiotics (Ciprofloxacin and Metronidazole), and schedule a follow-up in one week. Educate the patient on signs of complications and when to seek immediate care.