Hillcrest Medical Case 2
RADIOLOGY REPORT
Patient Name: Benjamin Engelhart
Patient ID: 112592 DOB: 10/05/ Age: 46 Sex: M
CT Scan No: 10-790031
Ordering Physician: Alex McClure, MD
Procedure: CT scan of abdomen and pelvis without contrast.
Date of Procedure: 11/14/2012
HISTORY: RLQ pain, no previous studies.
ABDOMEN: The lung basis appeared unremarkable. The liver, spleen, gallbladder, adrenals, kidneys and pancreas and abdominal aorta appeared unremarkable. The bowels seen on the study appeared thickened. Dilated appendix seen constant with acute appendicitis. Osseous 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. Prostate, seminal vesicles and urinary bladder appeared WNL. The bowels seen on the study appeared WNL, except for inflammatory changes of the appendix and seccum with acute appendicitis. Osseous structures of the pelvis appeared in tract with evidence of bilateral hip degenerative changes.
IMPRESSION:
1. Findings consistent with acute appendicitis 2. Degenerative changes of the hips
_________________________
Paula Reddy
NN:EF
D:
T:
DISCHAGE SUMMARY
Patient Name: Benjamin Engelhart
Patient ID: 112592 DOB: 10/05/ Age: 46 Sex: M
Date of Admission: 11/14/2012
Date of Discharge: 11/17/2012
Admitting Physician: Benard Kester, MD General Surgery
Procedures Performed: Laparoscopic appendectomy with placement of RLQ drain on 11/14/2012
Complications: None.
Discharge Diagnosis: Acute subapperative appendectomy perforated.
DIAGNOSTIC/IMAGING LABS: Lab results at the time of admission showed a WBC count of 13. CT scan done in the ED revealed an acute appendicitis with fleggon. HOSPITAL COURSE: The 46 years old Caucasian gentleman presented to the ED with a 3 day history of abdominal pain, however in the last 24 hours and it has________ migrated to the RLQ with anneorixia, guarding and elevated
Patient Name: Benjamin Engelhart
Patient ID: 112592 DOB: 10/05/ Age: 46 Sex: M
CT Scan No: 10-790031
Ordering Physician: Alex McClure, MD
Procedure: CT scan of abdomen and pelvis without contrast.
Date of Procedure: 11/14/2012
HISTORY: RLQ pain, no previous studies.
ABDOMEN: The lung basis appeared unremarkable. The liver, spleen, gallbladder, adrenals, kidneys and pancreas and abdominal aorta appeared unremarkable. The bowels seen on the study appeared thickened. Dilated appendix seen constant with acute appendicitis. Osseous 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. Prostate, seminal vesicles and urinary bladder appeared WNL. The bowels seen on the study appeared WNL, except for inflammatory changes of the appendix and seccum with acute appendicitis. Osseous structures of the pelvis appeared in tract with evidence of bilateral hip degenerative changes.
IMPRESSION:
1. Findings consistent with acute appendicitis 2. Degenerative changes of the hips
_________________________
Paula Reddy
NN:EF
D:
T:
DISCHAGE SUMMARY
Patient Name: Benjamin Engelhart
Patient ID: 112592 DOB: 10/05/ Age: 46 Sex: M
Date of Admission: 11/14/2012
Date of Discharge: 11/17/2012
Admitting Physician: Benard Kester, MD General Surgery
Procedures Performed: Laparoscopic appendectomy with placement of RLQ drain on 11/14/2012
Complications: None.
Discharge Diagnosis: Acute subapperative appendectomy perforated.
DIAGNOSTIC/IMAGING LABS: Lab results at the time of admission showed a WBC count of 13. CT scan done in the ED revealed an acute appendicitis with fleggon. HOSPITAL COURSE: The 46 years old Caucasian gentleman presented to the ED with a 3 day history of abdominal pain, however in the last 24 hours and it has________ migrated to the RLQ with anneorixia, guarding and elevated