TRUS PROSTATE BIOPSY (OR)
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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ASSISTANT: Dr. __
PREOPERATIVE DIAGNOSIS: elevated PSA
POSTOPERATIVE DIAGNOSIS: elevated PSA
PROCEDURE: Transrectal ultrasound guided prostate biopsy
FINDINGS: 45 gram prostate
ANESTHESIA: Local with sedation
INTRAVENOUS FLUIDS: IV crystalloid
ESTIMATED BLOOD LOSS: <5ml
TUBES AND DRAINS: None
SPECIMENS: 12 core prostate biopsy
INDICATIONS FOR PROCEDURE: The patient is a __ yr old who has been evaluated recently for elevated PSA. Dr. 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.
900mg clindamycin and 240mg gentamicin 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 agreeance and with Dr. ___ present for time out. The case began with ultrasound probe was inserted in the rectum. The prostate was measured and found to be 45 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 and was transferred to PACU in stable condition. Dr. ___ was present throughout the entire procedure.
PLAN: The patient will be discharged after meeting anesthesia criteria. Patient was given given prescriptions for norco and miralax. Discussed with patient the dangers of opioid addiction, how to properly dispose of an expired, unused, or unwanted controlled substance, the fact that delivery of a controlled substance is a felony under Michigan Law, the fact that opiates should not be taken with alcohol, sedatives or other central nervous system acting medications patient should not drive or make important decisions within 6 hours of taking an opiod and discussed the short and long-term effects of exposing a fetus to an opioid. Patient acknowledged and communicated understanding of while not under effects of anesthesia prior to the procedure. 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 with Dr. in 1-2 weeks.