Order 1103231: Clinical Case study post op

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DarrenRobertsDocumentation.docx

Darren Roberts Documentation

Enquiry One - Darren Roberts

Darren Roberts, 50 years admitted for Elective +/- Open Cholecystectomy

Darren's Story

Darren lives in Cairns where he is the owner/operator of a diving boat tour company. He has moved to a more sedentary role over the last few years and misses getting out and working with the tourists.

Darren has one son, Jake, 15 who lives in Wallan, Victoria with his mum Lisa, step dad Kevin and his 5-year-old stepsister Ruby.

Jake and Darren have a good relationship, Jake fly’s to Cairns twice a year during school holidays to stay with his Dad.

Darren’s History  

DOB: 23/11/1968

Address:  25 Happy Street Cairns

Smoker: 30 per day for last 20 years    

Social Drinker 2 heavy beers a day after work and up to 10 a day on the weekends - Darren’s favourite saying -It’s 5 o’clock somewhere’                                                       

^BMI -33 H: 1.8m W: 110Kg Waist: 115cm        

 

Darren has a past medical history including, hypertension, hyperlipidemia, mild depression and GORD. He currently takes medication for these conditions.       

· Hypertension

· Hyperlipidemia

· Mild Depression

· Gastric Oesophageal Reflux       

He has experienced two episodes of upper abdominal pain during the night with associated nausea and vomiting within the last month.    

Medications

Generic name

Trade name

Dose

Atorvastatin

Lipitor

10mg Daily

Atenolol

Noten

50mg  Daily

Sertraline

Zoloft

20mg  BD

Ranitidine

Zantac 

150mg daily

                                                                               

Darren does not attend regular check-ups with his GP. He last had his medicaitons reviewed when he presented to the GP around 12 months ago with his first presentation of upper abdominal pain, nausea and vomiting. He was commenced on Ranitidine at tis time.

In the last month, Darren has had two more severe episodes of upper abdominal pain with nausea & vomiting. He ignored the first episode and it settled after 24 hours. However, Darren has presented to the Emergency Department in Cairns 1/7 ago with similar symptoms but more severe.

Darren’s diagnosis is mild- severe Cholecystitis. Darren has been transferred to the surgical ward where he is awaiting an elective Laparoscopic +/- Open Cholecystectomy. Darren has had pre- operative blood pathology collected including his Cholesterol, which is reading high. This is part of Darren’s pre-operative work up.