Case 2 Pathology Report

PATHOLOGY REPORT

Patient Name: Benjamin Engelhart

Patient ID: 112592 Date of Birth: 10/05/- - - - Age: 46 Sex: Male

Pathology Report No.: 10-S-9044

Date of Admission and Surgery: 11/14/- - - -

Admitting Physician: Bernard Kester, MD

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 in formaling and labeled with patient’s name, patient’s ID number, and appendix. It consists of an appendix measuring 6 x 1.5 x 1.5 cm. There is periappendiceal fat attached to it which measures 6 x 4x 1 cm. The serosal surface is hemorrhagic. Upon opening the appendix there is purulent exudative material. The wall thickness measures 0.3 cm. Representative sections are submitted in 1 cassette. Microscopic description preformed.

BJM:pc
D:11/16/- - - -
T:05/10/2014

(Continued)

Pathology Report
Patient Name: Benjamin Engelhart
Patient ID: 112592
Date of Admission and Surgery: 11/14/- - - -
Page 2

MICROSCOPIC DIAGNOSIS: Appendix appendectomy. Necrotizing acute appendicitis.

____________________
Georgia Tamayo, MD

GT:pc

D:11/17/ - - - -
T: 10/05/2014
ICD Code: 633.1
CPT Procedural code: A-88304

C: Alex McClure, MD