Please note these are examples, read through the entire op report to ensure your Op report is accurate according to what you actually did
ESTIMATED BLOOD LOSS:
TUBES AND DRAINS: french way foley catheter
INDICATIONS FOR PROCEDURE: The patient is a yr old who has a history of . discussed the treatment options with patient who has agreed to have a Prior to the procedure today, the patient's history and physical was obtained and reviewed. Informed consent was obtained and all questions were satisfactorily answered. The risks and benefits of the procedure including were discussed, patient acknowledged and communicated understanding of these risks and wished to proceed with the procedure.
OPERATIVE DETAIL: The patient was transferred to the cystoscopy suite and placed on continuous pulse oximetry and cardiac monitoring by anesthesia. IV antibiotics were administered. IV sedation and general anesthetic were administered. The patient was placed in the dorsal lithotomy position and prepped and draped in sterile fashion. Time out was performed confirming patient, procedure, side, all in the room agreed. SCDs were on and functioning. A well lubricated french resectoscope sheath with a visual obturator with degree lens was inserted into the urethral meatus and advance and advanced into the bladder. Care was taken to keep the urethra lumen in center of view to minimize trauma to the urethra. In the urethra there The verumontanum was identified easily and the prostate was observed to be . Upon entering the bladder, the bladder was drained. Urine appeared and was sent for culture. The bladder was then partially filled and evaluated in a panendoscopic fashion. Both ureteral orifices able to be identified and were far from the bladder neck and median lobe. In the bladder there were mucosal lesions, trabeculations, diverticulum, stones and tumors. Once the primary survey was complete, the visual obturator was replaced with resectoscope sheath with a working element using a bipolar . The verumontanum was identified and marked with the bipolar to ensure we did not work distal to the verumontanum, ensuring external sphincter remains damage free. The external sphincter was protected throughout the whole procedure. The bipolar resectoscope was held proximal to the external sphincter and the verumontanum at all times. Attention was first directed at the median lobe, which was resected at the 5 and 7 o'clock position until adequate visualization was achieved. Then, attention went to the right lateral lobe, which was resected in a counterclockwise fashion from the 12 o'clock position to the 7 o'clock position, and then attention went to the left lateral lobe, which was resected in a clockwise fashion from the 12 o'clock position to the 5 o'clock position. Once an adequate channel was resected, the verumontanum was again identified and held proximal to the verumontanum at all times, confirming repeatedly no resection distal to the verumontanum. The bladder was then drained. The bladder was re-distended and a large working channel was identified. The anterior lobe was then resected adequately to maintain a large open channel. The bladder was then drained and re-distended and all bleeders were hemostatically identified and coagulated using the bipolar . Once hemostasis was achieved with the bladder undistended, the bladder was then distended. The cystoscope was removed. The external sphincter was protected throughout the whole procedure. Once the resectoscope was removed, the patient able to Crede without any difficulty. Then, a -French -way Foley catheter was placed into the urethral meatus and advanced to the bladder without any complication with mL of sterile water placed in the balloon port after confirming no blood was present that could potentially clog the balloon port. urine was expressed . The bladder was drained, all parts of the cystoscopic sheath, cystoscope and instruments were intact and removed from the patient. The amount of fluid drained from the bladder was the expected amount given the amount of fluid irrigated into the bladder. The patient's abdomen was palpated and there was no change in physical exam from before the procedure and patient was awakened by anesthesia and transferred to PACU in stable condition. The Foley catheter was set to dependent drainage. The patient tolerated the procedure well. was present throughout the whole procedure.
PLAN: The patient will be after meeting anesthesia criteria. Patient was given given prescriptions for . The patient understands if there is any nausea, vomiting, fever, chills, persistent or new pain or symptoms to come back to the Emergency Room for evaluation. The patient knows to expect some gross hematuria over the coming days. Patient will follow up in