RIGHT Proximal Ureter ESWL
Please note these are examples, read through the entire op report to ensure your Op report is accurate according to what you actually did
PREOPERATIVE DIAGNOSIS: right proximal ureter stone
POSTOPERATIVE DIAGNOSIS: right proximal ureter stone
PROCEDURE: right extracorporeal shockwave lithotripsy
FINDINGS: Shadowing defect in the area of the right proximal ureter, some expansion of this area with lightening of the shadowing in the proximal ureteral stone
ANESTHESIA: General with LMA
INTRAVENOUS FLUIDS: IV crystalloid
ESTIMATED BLOOD LOSS: None
TUBES AND DRAINS: None
INDICATIONS FOR PROCEDURE: The patient is a 30 yr old who has been evaluated recently for right ureteral calculus. I discussed the treatment options with patient who has agreed to have a right extracorporeal shockwave lithotripsy. Prior to the procedure today, the patient's history and physical was obtained and reviewed and the contraindications to the procedure were reviewed and confirmed to not be present including presence of pregnancy, renal or abdominal aortic aneurysm, coagulopathy, urinary tract infection. The risks and benefits of the procedure including pain, damage to organs, bleeding, hematoma, infection and complications from anesthesia and other complications were discussed, patient acknowledged and communicated understanding of these and wished to proceed with the procedure. Informed consent was obtained and all questions were satisfactorily answered.
OPERATIVE DETAIL: The patient was transferred to the operating room suite and placed on continuous pulse oximetry and cardiac monitoring by anesthesia. There were no antibiotics given. IV sedation and general anesthetic were administered. The patient was placed in the supine position over the Storz F2 lithotripter and the ultrasound probe. A discussion with anesthesia occurred regarding the risk of cardiac arrythmia and the need for vigilance. The stone was then identified using x-ray imaging and the patient was centered over the area of the stone on the ultrasound probe. At this point, anesthesia was administered. SCDs were on and functioning and a time-out was performed. Starting at a power of 5 and continuing only at the power of 5, the stone was shocked at 90 shocks per minute for a total of 3000 shocks. At the end of the procedure, there was noted to be expansion of the right proximal ureter , which was the only stone that was worked on during this procedure and lightening of the stone, giving some information that indicated there is some fragmentation of the stone. The patient did tolerate the procedure well, there were no arrythmias observed or reported from anesthesia and no skin changes observed over the area of shockwave. The patient was then transferred to PACU in stable condition. Please note that I was present throughout the entire length of the procedure.
PLAN: The patient will be discharged home after meeting anesthesia criteria. Prescriptions for norco, miralax and flomax 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 in the next month for follow up appointment and follow up KUB.