TRUS PROSTATE BIOPSY (office)
Please note these are examples, read through the entire op report to ensure your Op report is accurate according to what you actually did.
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ESTIMATED BLOOD LOSS:
INDICATIONS FOR PROCEDURE: The patient is a yr old who has been evaluated recently for . 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: Antibiotics including of was given intramuscularly. The patient was placed in the lateral recumbent position ultrasound probe was inserted in the rectum. ml of was administered in the area lateral to the base bilaterally. At this point 12-core prostate biopsies were obtained, they are obtained from the right and left portions of the prostate and on each side were taken from the apex, medial and base with biopsy taken from the medial and lateral portions of each of the respected spots. 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. was present throughout the entire procedure.
Patient was given given prescriptions for . The 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 .