History of Present Illness
Review of Systems
Past Medical History
Physical Examination
Essential Differential Diagnosis
Relevant Next Steps
Test Result 1
Test Result 2
Diagnosis
Treatment Orders
Question 1
Question 2
Question 3
Question 4
About the Case
Left-sided Abdominal Pain in a 45-yr-old Man
Past Medical History
Medical history
: Diabetes mellitus since his 20s that is well-controlled with oral drugs, diet, and exercise. Hypertension and hyperlipidemia both well-controlled on drugs. Obstructive sleep apnea for which he uses a CPAP machine. Recent deep venous thrombosis that developed after a long international flight and that is currently being treated with an oral anticoagulant. Denies history of UTIs, difficulty with urination, COPD, renal stones, and immunosuppressive disorders.
Surgical history
: Wisdom tooth extraction as a teenager; no abdominal surgical procedures.
Medications
: Lisinopril 10 mg daily, aspirin 81 mg daily, rosuvastatin 10 mg daily, rivaroxaban 20 mg daily, metformin 850 mg daily, and niacin 1 g daily.
Allergies
: No known drug allergies.
Family history
: Mother and father have hypertension; sibling has history of kidney stones.
Social history
: He denies current and previous tobacco use. He works at a desk job and swims laps at his local pool several times a week. All immunizations are up-to-date. He denies exposure to any sick contacts. For the past 15 yr, he has had unprotected sex only with his wife.
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