Identifying Data:

Full Name: V.L.

Address: Roslyn, New York

Date of Birth: XX/XX/1966

Date & Time: July 8, 2024 | 8AM

Location: St. Francis Hospital

Religion: Catholic

Source of Information: Self

Reliability: Reliable

Source of Referral: Self

Mode of Transport: Self

 

Chief Complaint: “My abdomen is bulging” x 4 weeks 

 

History of Present Illness: 

V.L. is a 57 year old male with a PMHx of HTN and familial hypercholesterolemia and PSHx of resection of a benign myofibroblastic tumor of the liver in January 2024. Patient reports bulging and weakness of the middle of his abdomen for the last few weeks. Approximately 4 weeks ago, he noticed a small bulge in the area of a previous surgical scar on his abdomen, which has progressively increased in size. He describes the bulge as more prominent when he coughs, lifts heavy objects, or strains during bowel movements. There is associated discomfort and occasional sharp pain at the site of the hernia, rated a 4/10. It is exacerbated by physical exertion and relieved by rest. He has not taken any medications to alleviate the discomfort. He denies any history of trauma to the abdomen. Denies fever, chills, nausea, vomiting, overlying erythema, changes in bowel habits, or difficulty passing urine.

 

Past Medical History: 

Myofibroblastic tumor – incidental liver mass finding 

HTN x 17 years 

Familial hypercholesterolemia 

 

Prior Hospitalizations: 

Denies

 

Childhood Illnesses: None 

 

Immunizations: Up to date, COVID (2021), influenza declined 

 

Screening Tests: 

Ophthalmologic – has not gone in ~7 years

Dental – November 2023

Prostate Cancer Screening – February 2024

Colonoscopy – December 2023, repeat in 2 years 

 

Past Surgical History:  

Laparoscopy converted to open partial hepatectomy of segment, Memorial Sloan Kettering NYC – January 2024

 

Medications: 

Amlodipine-Valsartan (Exforge) 5/160 mg, PO daily

Bisoprolol (Concor) 2.5 mg, PO daily

Denies OTC and herbal supplementation 

 

Ancillary physicians:

PCP: Sarah Javdan, MD

 

Allergies: 

No known food, drug, or environmental allergies. 

 

Family History: 

• Mother (Age 81) alive, medical hx of HTN
• Father, deceased at 75, patient did not share cause 
• Brother (Age 50) alive and well, medical hx of HTN 

 

Social History:

Mr. JC is a 57 year old, pleasant, married man, who lives in a house with his wife and is currently employed as a businessman. He adequately performs his IADLs/ADLs and feels comfortable returning to his home upon discharge.  

 

Habits: Endorses alcohol consumption but not currently. Has 1-2 drinks, once a week. Denies history of illicit substance use. Denies smoking/marijuana use. Patient endorses caffeine intake, drinking one 8-oz cup of coffee daily. 

Travel: Denies recent travel.  

Diet: Pt reports having a well balanced diet with an effort to adhere to dietary sodium restriction. He typically has oatmeal for breakfast and a cup of coffee with sugar and milk. For lunch, he has salads or a wrap. For dinner, he eats early and only eats whatever his wife cooks, with a serving of protein and vegetables daily. 

Exercise: Pt admits to exercise including playing Pickleball and running/jogging daily. 

Sleep: 6-8 hours a night with no difficulty. 

Safety Measures: Admits to wearing a seatbelt in moving vehicles. 

Sexual History: Pt is currently sexually active with his wife. No history of STIs.

Proxy: not appointed, discussed for patient to review

 

Review of Systems: 

General – Denies loss of appetite, fever, generalized weakness/fatigue, recent weight gain or loss, malaise, chills or night sweats.

Skin, hair, nails – Denies rash, pruritus, excessive sweating, skin changes, and hair changes. No clubbing, cyanosis, paronychia. 

Head – Denies headache, dizziness, denies head trauma, fainting, and hx of vertigo.

Eyes –  Denies visual changes, discharge, and photophobia. Last eye exam: ~7 years ago. 

Ears – Denies loss of hearing, ear infection, ear pain, ear drainage, tinnitus or use of hearing aids. 

Nose/Sinuses – Denies epistaxis, nasal congestion, discharge, swelling.  

Mouth/Throat – Denies sore throat, cough,bleeding gums, hoarseness. Last dental exam: Unknown.

Neck – Denies localized swelling/lumps or stiffness/decreased range of motion. 

Breasts – Denies skin changes, lumps, nipple discharge, pain.  

Pulmonary System – Denies SOB, coughing, DOE, hemoptysis or cyanosis. 

Cardiovascular System –  Denies chest pain, irregular rhythm, palpitations, edema of the legs, syncope. 

Gastrointestinal System – Reports feeling a bulge in his abdomen and muscle weakness. Denies decreased oral intake, nausea, vomiting, intolerance to specific foods, changes in stool, hematochezia, hemorrhoids, constipation, or diarrhea. 

Genitourinary System – Denies urinary frequency,  oliguria, incontinence or flank pain.

Nervous – Denies dizziness, gait disturbances, sensory disturbances, paresthesia, or changes in cognition/mental status. 

Musculoskeletal system – Denies joint pain, muscle soreness, bone deformity, swelling/stiffness.

Peripheral vascular system – Denies edema and erythema of the lower extremities, hx of blood clots, varicose veins.

Hematological System – Denies easy bruising, lymph node enlargement, anemia, blood transfusions.

Endocrine system – Denies hirsutism, excessive sweating, heat intolerance, excessive hunger/thirst. 

Psychiatric – Denies changes in mood, suicidal ideations, and changes in eating habits. Denies irritability. 

 

Physical Exam: 

 

General: 57-year old male appears as his stated age, well groomed male with proper posture and appropriately dressed for the weather. Awake, alert, and oriented to person, place, time and situation.

 

Vital Signs:

 

BP: 124/82 Seated; (L)

HR: 80 BPM, regular rate & rhythm 

RR: 10 breaths/min, unlabored 

Temperature: 97.6 °F, Oral (Tympanic)

SpO2: 100% Room Air 

Height: 6 ft 0 inches 

Weight: 226 lbs / 102.5 kg

BMI: 30.69 kg/m2

 

Heart:

Regular rate, rhythm, and amp. Distinct S1/S2 with no murmurs, splitting of S2, friction rubs, or S3/S4 appreciated. 

 

Thorax/Lungs:

Chest was symmetrical with no signs of deformities or trauma. Respirations were unlabored. Non-tender to palpation throughout. Clear to auscultation bilaterally. No wheezing, rales, rhonchi. 

 

Abdomen: 

Vertical midline surgical incision, extending from xiphoid to umbilicus. Midline bulge noted approximately 6 cm above the umbilicus. Hernia measures approximately 5 cm in diameter. Overlying skin is intact without signs of erythema or ulceration. +BS in all four quadrants. Hernia is non-reducible and slightly tender to palpation. Abdomen is symmetrical and non-distended. No guarding, rebound. 

 

Peripheral Vascular: No clubbing, cyanosis, or edema noted. Carotid pulses are 2+ bilaterally, no bruits present. 

 

Neurological: as noted in general survey. 

 

Skin, Hair, Nails, Head:

Skin: Warm and moist. Good turgor. No masses, scars, bruises, no ulcerations or tattoos. 

Hair: Appropriate quantity and even distribution. Color is dark brown, and the texture is normal. No visible dandruff or lice.

Nails: No clubbing, pitting, signs of infection. Presence of lunula on all nails. Capillary refill < 2 seconds in upper extremities.

Head: Normocephalic, atraumatic, non-tender to palpation throughout. No swelling noted.  

 

Eyes:

Eyes appear symmetrical with no bulging. No strabismus, nystagmus, lid lag, or ptosis seen. Sclera appears white, cornea clear with no signs of abrasion, and conjunctiva is clear. EOM intact.

 

Ears:

Symmetrical and appropriate in size, shape, and color. No masses/trauma on external ears. 

 

Nose/Sinus:

Nose was symmetrical with no evidence of deformities/discoloration/discharge/trauma. Mucosa was pink and well hydrated. Septum appeared midline with no perforations/inflammation/deviation. Inferior and middle turbinates were appreciated. No foreign bodies were detected. 

 

Mouth/Neck/Pharynx:

Lips: Pink, moist, no signs of cyanosis, no edema, cracks, ulcerations. 

Mucosa: Pink, well hydrated, no masses or ulcerations. 

Palate: Pink, well hydrated, no scars or ulcerations present.

Teeth: Good dentition, no missing teeth, no dental caries. 

Gingivae: Pink, moist, no erythema or hyperplasia present.

Tongue: Pink, symmetrical, well papillated. No white patches, discoloration, ulcerations. 

Oropharynx: No exudates, masses or foreign bodies. No tonsillar enlargement. Uvula pink, midline elevation with soft palate, no post-nasal drip. 

Neck: Trachea is midline. No masses, lesions, scars or pulsations noted. Non-tender to palpation.

Thyroid: Non-tender, no palpable masses, no enlarged thyroid. Symmetrical movement of isthmus upon swallowing.

 

Musculoskeletal Exam

Upper and Lower Extremities: No soft tissue swelling, erythema, ecchymosis, atrophy, or deformities in bilateral upper and lower extremities. Non-tender to palpation, no crepitus noted throughout. Full ROM of all upper and lower extremities bilaterally.  

 

Differential Diagnoses: 

• Ventral incisional hernia, incarcerated
• Epigastric hernia
• Incisional seroma 

 

Workup:

 

CBC w/ AutoDiff, CMP, Urinalysis

POCT Glucose: 116 (high)

PT/INR/PTT: within normal limits 

Urinalysis: normal

Imaging:

1. CT Abdomen and Pelvis with Contrast
   1. Impression: mild omental fat stranding deep to midline incision 

 

Assessment: 

A 57 year old male complaining of a bulge and weakness in his abdomen found to have an incarcerated incisional hernia s/p resection of a benign liver tumor in January 2024. Clinically, vital signs are stable and the patient is febrile with no signs of strangulation. CT abdomen/pelvis demonstrates mild omental fat stranding deep to midline incision. Patient is scheduled for an open incarcerated incisional hernia repair with mesh. 

 

Plan: 

 

1. Pre-Op:
   1. Trend labs (CBC, LFTs)
   2. IV Fluids – Sodium chloride 0.9% bolus 500 mL, followed by continuous lactated ringer’s infusion
2. Surgery Course:
   1. Open incarcerated incisional hernia repair with mesh scheduled for 7/9.
   2. Clear liquid diet for the day prior to surgery. NPO 4 hours prior to surgery 
   3. DVT prophylaxis → heparin (porcine) injection 5,000 units
3. Post-Op:
   1. Follow up 2 hours after PACU admission, post surgery.
   2. Pain control → oxycodone 5 mg Q4h PRN / dilaudid 1 mg injection Q15 min PRN
   3. Disposition → discharge after one night stay, pending hospital course post-op
   4. Diet → heart healthy 
   5. Activity → resume normal activity gradually, as tolerated. Avoid excessive abdominal strain, heavy lifting for 4-6 weeks. 
4. Chronic Medical Conditions
   1. Continue to manage HTN and HLD with PCP.