PATHOLOGY REPORT

Patient Name: Benjamin Engelhart

Hospital No.: 112592 DOB: 10/05/ AGE: 46 SEX: Male

Pathology Report No.: 10-S-9044 Date of Surgery: 11/14/

Admitting Physician: Bernard Kester, MD, General Surgery

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 formalin 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 4 x 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 one cassette.

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MICROSCOPIC DESCRIPTION: Performed.

MICROSCOPIC DIAGNOSIS: Appendix appendectomy: Necrotizing acute appendicitis.

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PATHOLOGY REPORT

Patient Name: Benjamin Engelhart

Patient ID: 112592
Date of Surgery: 11/14/
Page 2
ICD DIAGNOSIS CODE: 540.9

CPT PROCEDURAL CODE: A-88304

___________________
Georgia Tamayo, MD

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