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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SURGEON: Dr. __
PREOPERATIVE DIAGNOSIS: elevated PSA
POSTOPERATIVE DIAGNOSIS: elevated PSA
PROCEDURE: Transrectal ultrasound guided prostate biopsy
ESTIMATED BLOOD LOSS: <5ml
SPECIMENS: 12 core prostate biopsy
INDICATIONS FOR PROCEDURE: The patient is a __ yr old who has been evaluated recently for elevated PSA. I discussed the options with the patient who has agreed to have a transrectal ultrasound guided prostate 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, bleeding, hematoma, infection, sepsis 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: Antibiotics including 240mg of gentamicin was given intramuscularly. The patient was placed in the lateral recumbent position ultrasound probe was inserted in the rectum. 10ml of 1% lidocaine was administered in the area lateral to the base bilaterally and in the area lateral to the bilateral apex. The prostate was then measured and found to be ___ grams resulting in a final PSA density of ___ 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. The needle biopsy was dipped in formalin between each biopsy. 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. I was present throughout the entire procedure.
Patient was given given prescriptions for ciprofloxacin for 2 days , miralax. and norco. 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 in 1-2 weeks.