Operative Assessment Template

Patient Information:
- John Doe
- 45
- Male
- 123456
Presenting Complaint:
- Abdominal discomfort and bloating persisting for the last two weeks.
History of Presenting Complaint:
- The patient describes a gradual onset of abdominal discomfort, which has been continuous and worsening over the past two weeks. The discomfort is characterized as a dull ache, mainly in the lower abdomen, accompanied by bloating and occasional nausea.
Past Medical History:
- Appendectomy in 2010, hypertension.
Medications:
- Lisinopril 10 mg daily, multivitamin.
Allergies:
- Penicillin (rash).
Family History:
- Father diagnosed with colon cancer at age 60.
Social History:
- Employed as an accountant, non-smoker, consumes alcohol socially, no use of recreational drugs.
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 condition.
Plan:
- Initiate a clear liquid diet, prescribe antibiotics (Ciprofloxacin and Metronidazole), and arrange a follow-up in one week. Educate the patient on signs of complications and when to seek immediate care.