Benjamin Engelhart Essay

2246 Words Oct 5th, 2011 9 Pages
EMERGENCY SERVICES ADMISSION REPORT
Patient Name: Benjamin Engelhart
Patient ID: 112592
DOB 10/5/---- AGE: 46 SEX: Male
Date of Admission 11/14/----
Emergency Room Physician: Alex McClure, MD
Admitting Diagnosis: Acute Appendicitis
HISTORY OF PRESENT ILLNESS: This 46-year old gentleman with past medical history significant only for degenerative disease of the bilateral hips, secondary to arthritis presents to the emergency room after having had 3 days of abdominal pain. It initially started 3 days ago and was a generalized vague abdominal complaint. Earlier this morning the pain localized and radiated to the right lower quadrant. He had some nausea without emesis. He was able to tolerate p.o earlier around 6am, but he now
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Date of Procedure: 11/14/----
HISTORY: Right lower quadrant pain. No previous studies.
Abdomen: The lipases appeared unremarkable. The liver, spleen, gallbladder adrenals, kidneys, pancreas and abdominal aorta appeared unremarkable. The bowels seen on the study appeared thickened. Dilated appendix seemed consistent with acute appendicitis. All the structures of the abdomen appeared unremarkable. No free air was seen.
Pelvis: Good-quality, non- contrasted, actual CT examination of the pelvis with coronal reconstructions. The prostate seminal vesicles and urinary bladder appeared WNL. The bowels seen on the study appeared WNL, except for inflammatory changes of the appendix, and cecum consistent with acute appendicitis. .All the structures of the pelvis appeared intact with evidence of bilateral hip degenerative changes.
IMPRESSION: 1. Findings consistent with acute appendicitis.
2. Degenerative changes of the hips.

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Paula Reddy, MD Radiology

PR:ld
D: 11/14/----
T: 11/14/---- OPERATIVE REPORT
PATIENT NAME: Benjamin Engelhart
Patient ID: 112592 DOB: 10/5/---- AGE: 46 SEX: Male
Date of Admission: 11/14/----
Date of Procedure: 11/14/----
Admitting Physician: Bernard Kester, MD General Surgery
Surgeon: Bernard Kester, MD General Surgery
Assistant: Jason Wagner, PA-C Surgical Assistant
Circulating Nurse: Jimmy Dale Jett, RN
Preoperative
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