MRI FUSION TRUS PROSTATE BIOPSY
Please note these are examples, read through the entire op report to ensure your Op report is accurate according to what you actually did. If you see an error or way to may this better please contact us.
FINDINGS: gram prostate
ESTIMATED BLOOD LOSS:
TUBES AND DRAINS:
INDICATIONS FOR PROCEDURE: The patient is a yr old who has been evaluated recently for . Dr. discussed the options with the who agreed to have a 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 were discussed, acknowledged and communicated understanding of these risks and wished to proceed with the procedure.
OPERATIVE DETAIL: The patient was transferred to the operating room suite and placed on continuous pulse oximetry and cardiac monitoring by anesthesia. Antibiotics including mg and mg antibiotics given. IV sedation and general anesthetic were administered. The patient was placed in the lateral recumbant position and time out performed confirming team member introduced by name and role, patient confirmed with 2 identifiers, pre-op diagnosis, procedure to be performed, position and site/side confirmed, allergies reviewed, equipment/implants reviewed, images/radiographic films reviewed, meds and fluids for irrigation reviewed, DVT prophylaxis reviewd, beta blockers/antibiotics usage, glycemic control, blood product availability, warming measures in place and fire risk with all in agreement and with Dr. present for time out. The case began with ultrasound probe was inserted in the rectum. MRI fusion technology was used to overlay the MRI fusion biopsy with the tranrectal ultrasound image. There area of interest located in the cc ng/cc/ml. The region of interest was biopsied. A total of biopsies were obtained. These were then sent in formalin and sent for pathological examination. At the end of the procedure, the probe was removed. Pressure was held on the prostate and good hemostasis was noted. The patient tolerated the procedure well and was transferred to PACU in stable condition. Dr. was present throughout the entire procedure.
PLAN: The patient will be discharged home after meeting anesthesia criteria. Prescriptions for were provided. 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 to follow up with Dr. in 1-2 weeks for follow up appointment.