PLEASE NOTE THESE ARE EXAMPLES, READ THROUGH THE ENTIRE OP REPORT TO ENSURE YOUR OP REPORT IS ACCURATE ACCORDING TO WHAT YOU ACTUALLY DID
Cysto w/ biopsy: Male |
Cysto w/ biopsy: Female |
SURGEON: Dr. ____ ASSISTANT: Dr. ____ PREOPERATIVE DIAGNOSIS: Mucosal irregularity POSTOPERATIVE DIAGNOSIS: Mucosal irregularity PROCEDURE: Cystourethroscopy, bladder biopsy FINDINGS: 1.Bladder mucosa irregularity; 2. Unremarkable urethra and prostate ANESTHESIA: General with LMA INTRAVENOUS FLUIDS: IV crystalloid ESTIMATED BLOOD LOSS: Unable to determine due to dilution TUBES AND DRAINS: None SPECIMENS: Bladder mucosa COMPLICATIONS: None INDICATIONS FOR PROCEDURE: The patient is a _ year old who has a history of bladder mucosal irregularity. Dr. discussed the options with the patient who has agreed to have a cystourethroscopy with bladder biopsy. Prior to the procedure today, the patient's history and physical was reviewed. Informed consent was obtained and all questions were satisfactorily answered. The risks and benefits of the procedure including pain, damage to organs including the ureter, kidney, bladder, prostate, urethra, bleeding, pain, infection, bladder and ureter perforation and complications from anesthesia and other complications were discussed, the patient acknowledged and communicated understanding of these risks and wished to proceed with the procedure.
OPERATIVE DETAIL: The patient was transferred to the cystoscopy suite and placed on continuous pulse oximetry and cardiac monitoring by anesthesia. IV antibiotics including 2g ampicillin and 240mg of gentamicin were administered. IV sedation and general anesthetic were administered. The patient was placed in the dorsal lithotomy position and prepped and draped in the normal sterile fashion. Time out was performed confirming patient, procedure, side, all in the room agreed. SCDs were on and functioning A well lubricated 22 french cystoscopic sheath with a 30 degree lens was inserted into the urethral meatus and advanced into the bladder. Care was taken to keep the lumen in the center of view. In the urethra there were no urethral strictures, no mucosal lesions, no tumors, no polyps. The prostate was moderately enlarged and was not obstructive in nature. Upon entering the bladder, the bladder was drained. Urine was clear and was not sent for culture. The bladder was then partially filled and evaluated in a panendoscopic fashion using the 30 degree lens ,then 70 degree lens There were no mucosal lesions, no trabeculations, no diverticulum ,no stones and no tumors .. Our attention was directed to the lateral wall where we biopsied using the cold cup biopsy. A total of 1 biopsy was obtained. Prior to using the cold cup the bladder was evaluated carefully to ensure the bladder was sufficiently filled for the biopsy without being overdistended. When using the cold cup biopsy, care was taken to get a sufficient sample for pathology without going to far into the bladder wall to avoid a bladder perforation. Hemostasis was obtained with bugby electrocautery around the edge of the biopsy and the base of the biopsy. The bladder was drained, refilled and the bladder was evaluated closely for hemostasis, which was excellent with no active bleeding. All clots were evacuated from the bladder. The bladder was then drained. All parts of the cystoscopic sheath, cystoscope and all instruments were intact and removed from the patient. The patients abdomen was then palpated to ensure there was no change in physical exam. The patient was awakened by anesthesia and transferred to PACU in stable condition. Patient tolerated the procedure well. Please note that Dr. was present throughout the entire length of the procedure.
PLAN: The patient will be discharged after meeting anesthesia criteria. Patient was given given prescriptions for norco and miralax. Discussed with patient the dangers of opioid addiction, how to properly dispose of an expired, unused, or unwanted controlled substance, the fact that delivery of a controlled substance is a felony under Michigan Law, the fact that opiates should not be taken with alcohol, sedatives or other central nervous system acting medications patient should not drive or make important decisions within 6 hours of taking an opiod and discussed the short and long-term effects of exposing a fetus to an opioid. Patient acknowledged and communicated understanding of while not under effects of anesthesia prior to the procedure. The patient understands if there is any nausea, vomiting, fever, chills or develops gross hematuria, persistent or new pain or symptoms to come back to the Emergency Room for evaluation by urologic surgery.Patient will follow up with Dr. in 1-2 weeks.
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SURGEON: Dr. ____ ASSISTANT: Dr. ____ PREOPERATIVE DIAGNOSIS: Mucosal irregularity POSTOPERATIVE DIAGNOSIS: Mucosal irregularity PROCEDURE: Cystourethroscopy, bladder biopsy FINDINGS: 1.Bladder mucosa irregularity ANESTHESIA: General with LMA INTRAVENOUS FLUIDS: IV crystalloid ESTIMATED BLOOD LOSS: Unable to determine due to dilution TUBES AND DRAINS: None SPECIMENS: Bladder mucosa COMPLICATIONS: None INDICATIONS FOR PROCEDURE: The patient is a _ year old who has a history of bladder mucosal irregularity. Dr. discussed the options with the patient who has agreed to have a cystourethroscopy and bladder biopsy. Prior to the procedure today, the patient's history and physical was reviewed. Informed consent was obtained and all questions were satisfactorily answered. The risks and benefits of the procedure including pain, damage to organs including the ureter, kidney, bladder, urethra, bleeding, pain, infection, bladder and ureter perforation and complications from anesthesia and other complications were discussed, the patient acknowledged and communicated understanding of these risks and wished to proceed with the procedure.
OPERATIVE DETAIL: The patient was transferred to the cystoscopy suite and placed on continuous pulse oximetry and cardiac monitoring by anesthesia. IV antibiotics including 2g ampicillin and 240mg of gentamicin were administered. IV sedation and general anesthetic were administered. The patient was placed in the dorsal lithotomy position and prepped and draped in the normal sterile fashion. Time out was performed confirming patient, procedure, side, all in the room agreed. SCDs were on and functioning A well lubricated 22 french cystoscopic sheath with a 30 degree lens was inserted into the urethral meatus and advanced into the bladder. Care was taken to keep the lumen in the center of view. In the urethra there were no urethral strictures, no mucosal lesions, no tumors, no polyps. Upon entering the bladder, the bladder was drained. Urine was clear and was not sent for culture. The bladder was then partially filled and evaluated in a panendoscopic fashion using the 30 degree lens ,then 70 degree lens There were no mucosal lesions, no trabeculations, no diverticulum ,no stones and no tumors .. Our attention was directed to the lateral wall where we biopsied using the cold cup biopsy. A total of 1 biopsy was obtained. Prior to using the cold cup the bladder was evaluated carefully to ensure the bladder was sufficiently filled for the biopsy without being overdistended. When using the cold cup biopsy, care was taken to get a sufficient sample for pathology without going to far into the bladder wall to avoid a bladder perforation. Hemostasis was obtained with bugby electrocautery around the edge of the biopsy and the base of the biopsy. The bladder was drained, refilled and the bladder was evaluated closely for hemostasis, which was excellent with no active bleeding. All clots were evacuated from the bladder. The bladder was then drained. All parts of the cystoscopic sheath, cystoscope and all instruments were intact and removed from the patient. The patients abdomen was then palpated to ensure there was no change in physical exam. The patient was awakened by anesthesia and transferred to PACU in stable condition. Patient tolerated the procedure well. Please note that Dr. was present throughout the entire length of the procedure.
PLAN: The patient will be discharged after meeting anesthesia criteria. Patient was given given prescriptions for norco and miralax. Discussed with patient the dangers of opioid addiction, how to properly dispose of an expired, unused, or unwanted controlled substance, the fact that delivery of a controlled substance is a felony under Michigan Law, the fact that opiates should not be taken with alcohol, sedatives or other central nervous system acting medications patient should not drive or make important decisions within 6 hours of taking an opiod and discussed the short and long-term effects of exposing a fetus to an opioid. Patient acknowledged and communicated understanding of while not under effects of anesthesia prior to the procedure. The patient understands if there is any nausea, vomiting, fever, chills or develops gross hematuria, persistent or new pain or symptoms to come back to the Emergency Room for evaluation by urologic surgery.Patient will follow up with Dr. in 1-2 weeks.
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