CT scan of abdomen and pelvis without contrast Essay

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: 112592DOB: 10/05/Age: 46Sex: 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 WBC of 13 and CT scan consistent with appendicitis. The patient was taken to the operating room where he underwent a laparoscopic appendectomy that revealed appendix perforation and phlegmon. The appendix was removed in toto with an intact stable line. A drain was placed in the RLQ due to the fleggmonous material. Patient did well over the successive 2-3 days postoperatively with resumption of an oral diet having past flatus with having bowel movement with minimal drain output. However his WBC lowered to 6. His drain has been left intact. Patient is being discharged on the post operative day 3 on a 1 week course of PO gentamicin. The drain left in place. The drain will be removed in my office on 11/24/2012 if the drain output is minimal. Patient is on a PO diet. He was given a script for both antibiotics and PO narcotics. (Continued) PLAN: Post operative visit in my office in 1 week for evaluation and possible removal of JP drain. No heavy lifting for 4 weeks following surgery. Patient is to complete his full course of post operative antibiotics. DISCHAGE SUMMARY Patient is to report to the ED or my office earlier if any redness or foul smelling drainage out of the wound sit. Any swelling, fever, pain or any other concerns. Patient and his wife verbalized the understanding of the agreement with the above plan. Bernard Kester CC: Max Hirsch, MD D:11/14/2012 T:11/14/2012 HISTORY AND PHYSICAL EXAMINATION Patient Name: Benjamin Engelhart Patient ID: 112592DOB: 10/05Age: 46 Date of Admission: 11/14/2012 Emergency Room Physician: Alex McClure, MD Admission Diagnosis: Acute Appendicitis HISTORY OF PRESENT ILLNESS: 46 year old gentlemen with past medical history significant only for degenerative disease with bilateral degenerative disease of the hips. Secondary to arthritis. Presents to the Emergency room after having had 3 days of abdomen pain. It usually started 3 days ago and was generalized vague abdomen complaint. Earlier this morning the pain localized and radiated to the RLQ. He had some nausea without amesis. He was able to tolerate PO earlier around 6am. but now denies having an appetite. Patient had very small bowel movement earlier this morning that was not normal for him. He has not passes has the morning. ‘he is voiding well. 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. Hersch. PAST SURGICAL HISTORY: Negative MEDICATIONS: Piroxicam for degenerative joint disease of bilateral hips ALLERGIES: No known drug allergies SOCIAL HISTORY: Patient admits alcohol ingestion nightly and on weekends. Denies tobacco use and illicit drug us. He is married. FAMILY HISTORY: No history of cancer or inflammatory bowel disease in his family. REVIEW OF SYSTEMS;;12 point ROS was preformed and is negative except noted in above HIP, PMH and PSH. Careful attention was paid to endocrine, integumentary, pulmonary, renal and neurological exam PHYSICAL EXAMINATION: Vital Signs. TEMPERATURE: 101.0, Blood Pressure- 127/179, Heart Rate-129, Respirations- 185, Weight-215. Situations 96% on room air. Pain Scale- 8/10. HEENT-Normal cephalic, atrumatic pupils equally round and reactive to light. Extra ocular motions intact. ORAL: Shows oral pharynx clear but slightly dry mucosal membranes. TMS: Clear. NECK: Supple, No thrangegally or JVD. No cervical,  subclavicular, axilarry or lingual lymphinalpathy. HEART: Regular rate and rhythm. No thrills or murmur heard. LUNGS: Clear to aspiration bilateral. ABDOMEN: Obese with minimal bowel sounds, slightly distended there is RLQ tenderness with guarding and pinpoint rebound. Positive _____. Actuator signs with negative psoas side. RECTAL: No evidence of blood or masses. PROSTATE: WNL. EXTREMITIES: No clubbing, cyanosis, clots or edmea. 1+ pedal pulses bilaterally. NUERO: Cranial nerves 2-12 grossly intact. DIAGNOSTIC DATA: WBC was 13.4, Hemoglobin and hematocrit 15.4 and 45.8, platelets 206 with 89% shift. Sodium 133, Potassium 3.7,Chorlide 99, Bicarbonate 24, BUM and Creatine 18 and 1.1, Lukeuos 146, adermin 4.3, total bulliru,1.7, remainder of the LFTs is WNL. Urinary analysis reveals trace keytones with 100 mg per decimeter with small amount of blood. CT scan was preformed revealing evidence of acute appendicitis with parasitical inflammation as well as facilitation of appendix inflammation and haziness in aperparacifiacal dilation. There is evidence of degenerative joint disease in bilateral hips on the cat scan as well. ASSESTMENT PLAN: This 46 year old Caucasian gentleman has signs and symptoms and radiographical findings consistent with acute appendicitis without evidence of abscesses. The plan is to take him to the operating room for laproscopic possible open appendectomy and possible large bowel dissection should the case resisitated. Plan was discussed with patient with his wife. Risk, benefits and alternatives were discussed. There was no barriers to communication and all questions were answered appropatily The patient understands the plan and desires to proceed . (Continued) The plan was discussed with Dr. Keslerof general surgery who agrees and will take patient to operating room . Alex McClure, MD D:11/14/2012 T:11/14/2012 PATHOLOGY REPORT Patient Name: Benjamin Engelhart Patient ID: 112592 DOB: 10/05/Age: 46Sex: M Pathology Report No: 10-S-9044 Date of Surgery: 11/14/2012 Attending Physician: Bernard Kester, MD general surgery Preoperative Diagnosis: Acute appendicitis Postoperative Diagnosis: Necrotizing acute appendicitis Specimen Received: Appendix other than incidental Date specimen received: 11/14/2012 Date reported: 11/16/2012 CLINICAL HISTORY: Acute appendicitis. GROSS DESCRIPTION: The specimen was received in formily? With patient name, ID and appendix. It consist of a appendix measuring 6 x1.5Ãâ€"1.5 cm there periepdesial fat attached to it measuring 6Ãâ€"4 by1 cm. The cirrosal surface is hemmoraggric. Upon opening the appendix there is percudent exudates material. The wall thickness measures 0.3cm. Representive sections are present is 1 cassettes. MICROSCOPIC DESCRIPTION: Performed MICROSCOPIC DIAGNOSIS: Appendix appendectomy, Necrotizing acute appendicitis. ICD Diagnosis Code: 540.9 (Continued) CPT Code: 8-88304 Georgia Tamato,MD ALW: D:11/14/2012 T:11/14/2012 OPERTIVE REPORT Patient Name: Benjamin Engelhart Patient ID: 112592DOB: 10/05Age: 46Sex: M Date of Admission: 11/14/2012 Date of Procedure: 11/14/2012 Admitting Physician: Bernard Kester, MD General Surgery Surgeon: Bernard Kester, Assistant: Jason Wangner, PAC Circulating nurse: Jimmy Dale Jet, RN Preoperative diagnosis: Acute appendicitis. Post operative diagnosis: Perforated appendicitis. Operative Procedure: 1: Laparoscopic Appendectomy. 2: Placement of RLQ drain. Anesthesia: General endotracheal. Specimen Removed: 1 Necrotic appendix. IV Fluids: 1700 crystalloid. Estimated Blood Loss: 10mL. Urine Output: 300mL. Complications: None. INDICATIONS: This gentleman is a 46 year old Caucasian male that came in with a 3 day history of abdominal pain, however the pain worsened after 24 hours to the RLQ and caused a significant amount of anorixia. He presented to the ER department. CT scan to abdominals and pelvis showed acute appendicitis. Labs showed WBC at 13. Laparoscopic appendectomy procedure was explained along with the risk, benefits and possible complications. Patient voiced his desire to proceed. Patient was started on preoperative gentamicin. DESCRIPTION OF PROCEDURE: Patient was ID’d times 2 in the pre op holding area. A final timeout was held in the nursing area, anesthesia and surgical service during in which the patient ID was confirmed and the surgical site was initialed. He was given preoperative antibiotics. He was taken back to the OR and placed in the supine position. General endotracheal anesthesia was induced. SEDs were placed on his lower extremities. His Left arm was tucked to the side. Foley Catheter was placed. His abdomen was shaved and prepped with betadine solution, and draped in the usual standard fashion. A small semicircular umbilical incision was made to the subcutaneous tissue down to the fascia. And was gasped at either side and was incised. Kelly clamped was easily inserted. Stay sutures made a _____on either side the Hasson trocar was placed and pneumoperitoneum was easily  achieved. 10 mL port was placed in Left abdomen and a 5 mL was placed in the LLQ. Inspection of RLQ showed a significant amount of adhesions and the small bowel trying to wall off perforated appendix. Milky purulent exudates was noted in surrounding area. The small bowel was carefully peeled off the RLQ side wall. Fibrous exudate the vermiform appendix was identified. It was neurotic perforated in appearance The cecum was mobilized by taking down the lateral attachments laterally. The adhesions of the terminal illium through the pelvis were significant, attempts at this time were not made to free them. There was no evidence of obstruction. The base of the appendix was Identified and dissected and lifted free. Stapler loaded with___ was used to transect the base______however again inflammation extended to the level of the cecum. Though the cecum itself was also inflamed. The remainder of the mesoappendix was divided with a Endo GIA loaded with a _____. Appendix was placed into a endo catch bag was brought out through the umbilical cord site and sent to pathology for routine processing. Inspection of the RLQ and the area was irrigated coupsuley, there was no further evidence of purulent exudate. The appendicualr stump remained and doesn’t appear to be inflamed. However____wasn’t bl eeding. There was some fibrous exudate in the area. Consequently I felt like we had 2 options, we either perform a right epicolodectomy, given the intent of the adhesions in the pelvis would likely require a laparotomy or place a drain with antibiotics possibly controlling the fistula until the inflammation resolves. But hopefully it will heal on its own spontatensouly. Consequently we placed a19 French round Blake drain in the RLQ and brought it out through the LLQ in the 5mm port site. It was secured to the skin using a micro suture. Nuenopartiumeum was then desufflated the fascia of the umbilical port site was closed using a 2,o vicro that had been previously placed. All wounds were enthsitized using 1/2% marking solution and was coupsley irrigated. Skin edges approximated using 4 or monocro. The wounds were dressed with beatdine spray and steri strips. Drain sponge was placed around the drain, Foley catheter was removed. The patient was awakened, exubated then taken to recovery PAR in stable condition. Having tolerated the procedu re well. No complications were observed. DISPOSISTION: 1: The patient will be transferred to the floor. 2: He will be kept at least overnight. 3: He will be taught drain care. 4: He will go home with the drain on place. 5: He may require a fistulagram in the future. Benard Kester, MD D:11/14/2012 T:11/14/2012