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, R RPG: Male
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Cysto, R RPG: Female
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SURGEON: Dr. _ ASSISTANT: _ PREOPERATIVE DIAGNOSIS: Hematuria POSTOPERATIVE DIAGNOSIS: Hematuria PROCEDURE: Cystourethroscopy, right retrograde pyelograms FINDINGS: Unremarkable bladder, urethra, prostate and right collecting system ANESTHESIA: General with LMA INTRAVENOUS FLUIDS: IV crystalloid ESTIMATED BLOOD LOSS: None TUBES AND DRAINS: None SPECIMENS: None COMPLICATIONS: None INDICATIONS FOR PROCEDURE: The patient is a _ yr old who has a history of hematuria . I discussed the options with the patient who has agreed to have a cystourethroscopy, right retrograde pyelogram. 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 1 gram of ancef 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 mildly 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. We then directed our attention to the right ureteral orifice which we cannulated with an open ended ureteral catheter and shot about 7ml of conray dye and used fluoroscopy to delineate the collecting system on the right. There was no hydroureter, no hydronephrosis, no strictures, no filling defects, no blunting of the calyces, no contrast extravasation and the ureter was normal in course and caliber. We then removed the open ended ureteral catheter from the right ureteral orifice and observed drainage of the collecting system by direct visualization and with fluoroscopy. There was good drainage of the right collecting system. The bladder was drained, all parts of the cystoscopic sheath, cystoscope and instruments were intact and removed from the patient. The amount of fluid drained from the bladder was the expected amount given the amount of fluid irrigated into the bladder. The patient's abdomen was palpated and there was no change in physical exam from before the procedure and patient was awakened by anesthesia and transferred to PACU in stable condition. Patient tolerated the procedure well and was transferred to the PACU in stable condition.. Please note that I 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 nothing at this time. 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. Patient will follow up in 1-2 weeks.
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SURGEON: Dr. _ ASSISTANT: _ PREOPERATIVE DIAGNOSIS: Hematuria POSTOPERATIVE DIAGNOSIS: Hematuria PROCEDURE: Cystourethroscopy, right retrograde pyelograms FINDINGS: Unremarkable bladder, urethra and right collecting system ANESTHESIA: General with LMA INTRAVENOUS FLUIDS: IV crystalloid ESTIMATED BLOOD LOSS: None TUBES AND DRAINS: None SPECIMENS: None COMPLICATIONS: None INDICATIONS FOR PROCEDURE: The patient is a _ yr old who has a history of hematuria . I discussed the options with the patient who has agreed to have a cystourethroscopy, right retrograde pyelogram. 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 1 gram of ancef 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. We then directed our attention to the right ureteral orifice which we cannulated with an open ended ureteral catheter and shot about 7ml of conray dye and used fluoroscopy to delineate the collecting system on the right. There was no hydroureter, no hydronephrosis, no strictures, no filling defects, no blunting of the calyces, no contrast extravasation and the ureter was normal in course and caliber. We then removed the open ended ureteral catheter from the right ureteral orifice and observed drainage of the collecting system by direct visualization and with fluoroscopy. There was good drainage of the right collecting system. The bladder was drained, all parts of the cystoscopic sheath, cystoscope and instruments were intact and removed from the patient. The amount of fluid drained from the bladder was the expected amount given the amount of fluid irrigated into the bladder. The patient's abdomen was palpated and there was no change in physical exam from before the procedure and patient was awakened by anesthesia and transferred to PACU in stable condition. Patient tolerated the procedure well and was transferred to the PACU in stable condition.. Please note that I 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 nothing at this time. 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. Patient will follow up in 1-2 weeks.
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