Benjamin Engelhart

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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.

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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.

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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:...
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