EMERGENCY SERVICES ADMISSION REPORT Patient Name: Benjamin Engelhart Patient ID: 112592 DOB 10/5/—-AGE: 46SEX: 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 denies having an appetite. Patient had a very small bowel movement early this morning that was not normal for him. He has not passed gas this morning. He’s voiding well. He denies fevers, chills, or night sweats. The pain is localized to the RLQ without radiation at this point. He has never had a colonoscopy. PAST MEDICAL HISTORY: Significant for arthritis of bilateral hips. Seen by Dr.
Hirsch. PAST SURGICAL HISTORY: Negative MEDICATIONS: Piroxicam for the degenerative joint disease bilateral hips. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Patient admits to alcohol ingestion nightly and on weekends. Denies tobacco use. Denies illicit drug use. He is married. FAMILY HISTORY: There is no history of cancer or inflammatory bowel disease in his family. REVIEW OF SYSTEMS: A 12-point review of systems was performed and is negative except as noted above in the History of Present Illness, Past Medical and Past Surgical History.
Careful attention is paid to endocrine, cardiac, pulmonary, hepatobiliary, renal, integument and neurologic exams. (Continued) ? EMERGENCY SERVICES ADMISSION REPORT Patient Name: Benjamin Engelhart Patient ID: 112592 Date of Admission 11/14/—- Page 2 PHYSICAL EXAMINATION: Vital signs: Temperature 101. 0, blood pressure 127/79, heart rate 129, respirations 18, weight, 215 lbs. Saturations 96% on room air. The pain scale is 8 out of 10. HEENT: Normocephalic pain traumatic. Pupils: Equally round and reactive to light. Extraocular motions intact. Oral cavity shows oropharynx clear, but slightly dried mucosal membranes.
TMs clear. Neck: Supple. There is no thyromegaly. No JVD. No cervical supraclavicular, axillary, or adenal lymphadenopathy. Heart: Regular rate and rhythm. No thrills or murmurs heard. Lungs: Clear to auscultation bilateral. Abdomen: Obese with minimal bowel sounds Slightly distended. There is RLQ tenderness with guarding and with pinpoint rebound. Positive McBurney and obturator signs with a negative psoas sign. Rectal exam revealed no evidence of blood or masses. Prostate: WML Extremities: No clubbing, cyanosis, clots or edema. There are 1+ fetal pulses bilaterally.
Neural: Cranial nerves 2 through 12 grossly intact. (Continued) EMERGENCY SERVICES ADMISSION REPORT Patient Name: Benjamin Engelhart Patient ID: 112592 Date of Admission 11/14/—- Page 3 DIAGNOSTIC DATA: White count was 13. 4, Hemoglobin and hematocrit 15. 4 and 45. 8. Platelets 206 with a 89% shift. Sodium 133. Potassium, 3. 7. Chloride 99. Bicarb 24. BUN and creatinine are 18 and 1. 1 respectfully. Glucose 146. Albumum 4. 3 Cortal bilirubin 1. 7. The remainder of the LFTs is within normal limits. Urinalysis reveals trace t counts with 100mg/dL protein and a small amount of blood.
CT scan was performed revealing evidence of acute appendicitis with pericecal inflammation as well as dilatation of the appendix and inflammation and haziness in the periappendiceal sac. There is evidence of degenerative joint disease in bilateral hips on the CAT scan as well. _________________________ Alex McClure, MD ER Physician AM:ld D:11/14/—- T:11/14/—- ? DIAGNOSTIC IMAGING REPORT: CT Scan Patient Name: Benjamin Engelhart Patient ID: 112592DOB: 10/05/—-Age: 46Sex: Male CT Scan No: 10-790031 Ordering Physician: Alex McClure, MD Procedure: CT Scan of abdomen and pelvis without contrast.
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. _________________________ Paula Reddy, MD Radiology PR:ld D: 11/14/—- T: 11/14/—- ? OPERATIVE REPORT PATIENT NAME: Benjamin Engelhart Patient ID: 112592DOB: 10/5/—-AGE: 46SEX: 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 Diagnosis: Acute appendicitis. Postoperative Diagnosis: Perforated appendicitis. Operative Procedure: 1. Laparoscopic appendectomy 2. Placement of right lower quadrant drain Anesthesia: General Endotracheal tube anesthesia Specimen Removed: One necrotic appendix I. V Fluids: 1700 mL crystalloid Estimated Blood Loss: 10 mL Urine Output: 300 mL COMPLICATIONS: None
Indications: This gentleman is a 46-year old Caucasian male with a 3 day history of abdominal pain. However, over the past 24 hours his pain is located to the right lower quadrant and caused a significant amount of anorexia. He presented to the emergency department. CT scan of abdomen and pelvis revealed acute appendicitis. Lab showed a WBC count of 13. The laparoscopic appendectomy procedure was explained, along with the risks, benefits and possible complications. Patient voiced his desire to proceed. Patient was started on preoperative gentamicin. DESCRIPTION OF PROCEDURE:.
The patient was identified x2 in the preoperative holding area. A final time out was held with the nursing service, anesthesia and the surgical service during which the patient’s ID was comfirmed, and his surgical site was initialed. (continued) OPERATIVE REPORT PATIENT NAME: Benjamin Engelhart Patient ID: 112592DOB: 10/5/—-AGE: 46SEX: Male Date of Admission: 11/14/—- Page 2 He was given perioperative antibiotics. He was taken back to the operating room and placed in the supine position. General ET anesthesia was induced. SCDs were placed on his lower extremities.
His left arm tucked at his side, a Foley catheter was placed. His abdomen was shaved. Prepped with Betadine solution and draped in the usual standard fashion. A small semi-circular infra umbilical incision was made and carried down to the subcutaneous tissue to the level of the fascia. The fascia was grasped from either side and incised. The Kelly clamp easily inserted into the abdomen. Stay sutures made of Vicryl were placed on either side. A Hasson trocar was placed and pneumoperitoneum was easily achieved. In the left abdomen. a 10mm port was placed in the left mid-abdomen, and a 5mm port was placed in the left lower quadrant.
Inspection of the right lower quadrant revealed a significant amount of adhesions from the small bowel triangle? wall off this perforated appendix. Milky purulent exudates was noted in the surrounding area. The small bowel was carefully peeled off the right lower quadrant side wall. There was fibrinous exudate. The vermiform appendix was identified. It was necrotic and perforated in appearance. The secum was mobilized by taking down the lateral attachments laterally. The adhesions of the terminal ilium into the pelvis were significant. Attempts were not made at this time to free them.
There was no evidence of obstruction. The base of the appendix was identified and dissected free. The stapler loaded with the blue load was used to transect the base. However, again, inflammation extended to the level of the secum. The secum itself was also inflamed. The remainder of the mesoappendix was divided with an Endo GIA and loaded with a white load. The appendix was placed in an Endo Catch bag and brought out through the umbilical port site and sent to pathology for routine processing. INSPECTION OF THE RIGHT LOWER QUADRANT: Area irrigated copiously. There was no further evidence of purulent exudates.
The appendicile stump remaining did appear to be inflamed, however, it was not bleeding. There was also some fibrinous exudates in the area. Consequently, I felt we had two options. (continued) OPERATIVE REPORT PATIENT NAME: Benjamin Engelhart Patient ID: 112592DOB: 10/5/—-AGE: 46SEX: Male Date of Admission: 11/14/—- Page 3 We either performed a right hemicolectomy, though given the extent of the adhesions in the pelvis, this would likely require a laparotomy, or, replace a drain with antibiotics, possibly controlling this fistula until the inflammation resolves.
Hopefully it will heal on its own spontaneously. Consequently we placed a 19-French Round Blake drain in the right lower quadrant and brought it out to the left lower quadrant 5mm port site. It was secured to the skin using a Vicryl suture. The pneumoperitoneum was then desufflated. The fascia of the umbilical port site was then closed with a 2-0 Vicryl that had been previously placed. All the wounds were anesthetized with 0. 5% Marcaine solution. The wounds were copiously irrigated. Skin peges? approximated using 4-0 monochryl. The wounds were then dressed with Betadine spray and Steri-Strips.
A drain sponge was placed around the drain. The Foley catheter was removed. The patient was awakened, extubated and taken to PAR in stable condition as having tolerated the procedure well. No complications were observed. DISPOSITION: 1. The patient will be transferred to the floor. 2. He will be kept at least overnight. 3. He will be taught drain care. 4. He will go home with a drain in place 5. He may require a fistulogram in the future. _________________________ Bernard Kester, MD General Surgery BK:ld D:11/14/—- T:11/14/—- PATHOLOGY REPORT PATIENT NAME: Benjamin Engelhart Patient ID: 112592
Date of Birth: 10/5/—- Age: 46 Sex: Male PATHOLOGY REPORT N0. : 10-S-9044 Date of Surgery: 11/14/—- Admitting Physician: Bernard Kester, MD General Surgery Preoperative Diagnosis: Acute appendicitis. Postoperative Diagnosis: Necrotizing acute appendicitis. SPECIMEN RECEIVED: Appendix , other than incidental DATE RECEIVED: 11/14/—- DATE REPORTED: 11/16/—- CLINICAL HISTORY: Acute appendicitis. GROSS DESCRIPTION: The specimen is received for mailing and labeled with patient’s name , patient’s ID number and appendix. It consists of an appendix measuring 6 x 1. 5 x 1. 5cm.
There is purulent and visual fat attached to it which measures 6×4 x1 cm. The serosal surface is hemorrhagic. Upon opening the appendix , there is purulent exudated material. The wall thickness measures 0. 3cm. Representative sections are submitted in one cassette. MICROSCOPIC DESCRIPTION: Performed MICROSCOPIC DIAGNOSIS: Appendix appendectomy. Necrotizing acute appendicitis ICD DIAGNOSIS CODE: 54019 CPT PROCEDURAL CODE: A-88304 _________________________ Georgia Tamayo, MD Pathology GT:ld D:11/16/—- T:11//16/—- DISCHARGE SUMMARY Patient Name: Benjamin Engelhart Patient ID: 112592DOB: 10/05/—-Age: 46Sex: Male
Date of Admission: 11/14/—- Date of Discharge: 11/17/—- Admitting Physician: Bernard Kester, MD General Surgery Procedure Performed: Laparascopic Appendectomy with placement of right lower quadrant drain on 11/14/—- Complications: None Discharge Diagnosis: Acute separative appendicitis perforated. DIAGNOSTIC LAB/IMAGING: DATA ON ADMISSION: Lab results at the time of admission showed a WBC count of 13. CT Scan done in the ED, revealed an acute appendicitis with phlegmon. HOSPITAL COURSE: This 46-year-old Caucasion gentleman presented to the ED with a 3-day history of abdominal pain.
However, over the past 24 hours it had radiated and migrated to the right lower quadrant, causing a significant amount of anorexia with some guarding. With an elevated White Blood Cell Count of 13 and a CT Scan consistent with appendicitis, the patient was taken to the operating room where he underwent a laparoscopic appendectomy. They revealed perforation of the appendix with a phlegmon. The appendix was removed in total with an intact stable line. A drain was placed in the right lower quadrant due to the phlegmonous material. Patient did well over the successive 2-3 days post-operatively with resumption of oral diet.
Having passed flatus and having had bowel movements with minimal pain and minimal drain output. However, his white blood cell count lowered to 6. His drain has been left intact. Patient is being discharged on postoperative day 3 on a one week course of p. o. gentamicin with the drain being left in place. The drain will be removed in my office on 24 November, should the drain output be minimal. Patient is on a p. o. diet. He was given a prescription for both the antibiotics and p. o. narcotics. (Continued) ? DISCHARGE SUMMARY Patient Name: Benjamin Engelhart Patient ID: 112592 Date of Discharge: 11/17/—-
Page 2 PLAN: Postoperative visit in my office in one week for evaluation and possible removal of JP drain. No heavy lifting for 4 weeks following surgery. Patient is to complete his full course of post-op antibiotics. Patient is to report to the E. D. or to my office earlier for any redness, or foul smelling drainage at the wound site. Any swelling, fever, pain, or any other concerns. The patient and his wife verbalized understanding of agreement with the above plan. _________________________ Bernard Kester, MD General Surgery BK:xx D:11/17/—- T:11/17/—- c. c: Max L Hirsch, MD, Orthopedic Surgery