Benjamin Engelhart
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 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:
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 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: