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 …show more content…

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.
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OPERATIVE REPORT
PATIENT NAME: Benjamin Engelhart
Patient ID: 112592 DOB: 10/5/---- AGE: 46 SEX: Male Date of Admission: 11/14/----
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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