1- Proofread and format the supplied text of Operative Report. Using the guidelines, transcription rules and report form
Posted: Mon May 02, 2022 8:28 pm
1- Proofread and format the supplied text of Operative Report. Using the guidelines, transcription rules and report format . Doctor benard kester here. It’s 11 14 and I’m dictating a report an operative report on benjamin engelhart. His id number is 112592. His date of birth is 10 5 age 46 sex male. His date of admission is today 11 14 and the date of procedure is also today 11 14. Admitting physician benard kester, md, general surgery, surgeon same. Assistant jason wagner pac. Circulating nurse jimmy dale jet, rn. Preoperative diagnosis acute appendicitis. Postoperative diagnosis perforated appendicitis. Operative procedure number one laparoscopic appendectomy number two placement of right lower quadrant drain. Anesthesia general endotracheal tube anesthesia Specimen removed one necrotic appendix Iv fluids 17 hundred millilitres crystalloid estimated blood loss ten millilitres urine output 300 millilitres. Complications none. Indications this gentleman is a 46 year old caucasian male with a three day history of abdominal pain, however, over the past 24 hours his pain has located to the right lower quadrant and caused a significant amount of anorexia. He presented to the emergency department. Ct scan of abdomen and pelvis revealed acute appendicitis. Labs showed a wbc count of 13. The laparoscopic appendectomy procedure was explained along with the risks, benefits, and possible complications. Patient voiced his desire to proceed. Patient was started on preop gentamiacin. Description of procedure the patient was identified times two in the preoperative holding area. A final time out was held with the nursing service, anesthesia, and the surgical service during which the patient’s id was confirmed, and his surgical site was initialed. He was given perioperative antibiotics. He was taken back to the operating room and placed in the supine position. General et anesthesia was induced. Scds were placed on his lower extremities. His left arm was tucked at his side. A foley catheter was placed. His abdomen was shaved, prepped with betadine solution, and draped in the usual standard fashion. A small semicircular infraumbilical incision was made and carried down through the subcutaneous tissue to the level of the fascia. The fascia was grasped on either side and incised. A kelly clamp easily inserted into the abdomen. Stay sutures made of vicril were placed on either side. A hasson trocar was placed and pneumoperitoneum was easily achieved. In the left abdomen, a ten mm port was placed in the left mid abdomen, and a five mm port was placed in the left lower quadrant. Inspection of the right lower quadrant revealed a significant amount of adhesions from the small bowel trying to wall off this perforated appendix. Milky purulent exudate was noted in the surrounding area. The small bowel was carefully peeled off the right lower quadrant sidewall. There was fibrinous exudate. The vermiform appendix was identified. It was necrotic and perforated in appearance. The cecum was mobilized by taking down the lateral attachments laterally. The adhesions of the terminal ileum into the pelvis were significant. Attempts were not made at this time to free them. There was no evidence of obstruction. The base of the appendix was identified and dissected free. A stapler loaded with a blue load was used to transect the base however, again, the inflammation extended to the level of the cecum. The cecum itself was also inflamed. The remainder of the mesoappendix was divided with an endo gia loaded with a white load. The appendix was placed in an endo catch bag and brought out through the umbilical port site and sent to pathology for routine processing. Inspection of the right lower quadrant, area irrigated copiously. There was no further evidence of purulent exudate. The appendiceal stump remaining did appear to be inflamed however, it was not bleeding. There was also some fibrinous exudate in the area. Consequently, i felt we had two options. we either perform a right hemicolectomy, though given the extent of the adhesions in the pelvis, this would likely require a laparotomy, or we place a drain with antibiotics, possibly controlling this fistula until the inflammation resolves. Hopefully it will heal on its own spontaneously. Consequently, we placed a 19 french round blake drain in the right lower quadrant and brought it out through the left lower quadrant 5 millimeter port site. It was secured to the skin using a vicril suture. The pneumoperitoneum was then desufflated. The fascia of the umbilical port site was closed with two oh vicril that had been previously placed. All wounds were anesthetized with point 5 percent marcaine solution. The wounds were copiously irrigated. Skin edges approximated using 4 O monocril. The wounds were then dressed with betadine spray and steristrips. A drain sponge was placed around the drain. The foley catheter was removed. The patient was awakened extubated and taken to par in stable condition, having tolerated the procedure well. No complications were observed.Disposition number one the patient will be transferred to the floor. number two he will be kept at least overnight. Number three he will be taught drain care. Number four he will go home with the drain in place. Number five he may require a fistulogram in the future. Doctor kester signing out. *
1- Proofread and format the supplied text of Operative Report. Using the guidelines, transcription rules and report format . Doctor benard kester here. It’s 11 14 and I’m dictating a report an operative report on benjamin engelhart. His id number is 112592. His date of birth is 10 5 age 46 sex male. His date of admission is today 11 14 and the date of procedure is also today 11 14. Admitting physician benard kester, md, general surgery, surgeon same. Assistant jason wagner pac. Circulating nurse jimmy dale jet, rn. Preoperative diagnosis acute appendicitis. Postoperative diagnosis perforated appendicitis. Operative procedure number one laparoscopic appendectomy number two placement of right lower quadrant drain. Anesthesia general endotracheal tube anesthesia Specimen removed one necrotic appendix Iv fluids 17 hundred millilitres crystalloid estimated blood loss ten millilitres urine output 300 millilitres. Complications none. Indications this gentleman is a 46 year old caucasian male with a three day history of abdominal pain, however, over the past 24 hours his pain has located to the right lower quadrant and caused a significant amount of anorexia. He presented to the emergency department. Ct scan of abdomen and pelvis revealed acute appendicitis. Labs showed a wbc count of 13. The laparoscopic appendectomy procedure was explained along with the risks, benefits, and possible complications. Patient voiced his desire to proceed. Patient was started on preop gentamiacin. Description of procedure the patient was identified times two in the preoperative holding area. A final time out was held with the nursing service, anesthesia, and the surgical service during which the patient’s id was confirmed, and his surgical site was initialed. He was given perioperative antibiotics. He was taken back to the operating room and placed in the supine position. General et anesthesia was induced. Scds were placed on his lower extremities. His left arm was tucked at his side. A foley catheter was placed. His abdomen was shaved, prepped with betadine solution, and draped in the usual standard fashion. A small semicircular infraumbilical incision was made and carried down through the subcutaneous tissue to the level of the fascia. The fascia was grasped on either side and incised. A kelly clamp easily inserted into the abdomen. Stay sutures made of vicril were placed on either side. A hasson trocar was placed and pneumoperitoneum was easily achieved. In the left abdomen, a ten mm port was placed in the left mid abdomen, and a five mm port was placed in the left lower quadrant. Inspection of the right lower quadrant revealed a significant amount of adhesions from the small bowel trying to wall off this perforated appendix. Milky purulent exudate was noted in the surrounding area. The small bowel was carefully peeled off the right lower quadrant sidewall. There was fibrinous exudate. The vermiform appendix was identified. It was necrotic and perforated in appearance. The cecum was mobilized by taking down the lateral attachments laterally. The adhesions of the terminal ileum into the pelvis were significant. Attempts were not made at this time to free them. There was no evidence of obstruction. The base of the appendix was identified and dissected free. A stapler loaded with a blue load was used to transect the base however, again, the inflammation extended to the level of the cecum. The cecum itself was also inflamed. The remainder of the mesoappendix was divided with an endo gia loaded with a white load. The appendix was placed in an endo catch bag and brought out through the umbilical port site and sent to pathology for routine processing. Inspection of the right lower quadrant, area irrigated copiously. There was no further evidence of purulent exudate. The appendiceal stump remaining did appear to be inflamed however, it was not bleeding. There was also some fibrinous exudate in the area. Consequently, i felt we had two options. we either perform a right hemicolectomy, though given the extent of the adhesions in the pelvis, this would likely require a laparotomy, or we place a drain with antibiotics, possibly controlling this fistula until the inflammation resolves. Hopefully it will heal on its own spontaneously. Consequently, we placed a 19 french round blake drain in the right lower quadrant and brought it out through the left lower quadrant 5 millimeter port site. It was secured to the skin using a vicril suture. The pneumoperitoneum was then desufflated. The fascia of the umbilical port site was closed with two oh vicril that had been previously placed. All wounds were anesthetized with point 5 percent marcaine solution. The wounds were copiously irrigated. Skin edges approximated using 4 O monocril. The wounds were then dressed with betadine spray and steristrips. A drain sponge was placed around the drain. The foley catheter was removed. The patient was awakened extubated and taken to par in stable condition, having tolerated the procedure well. No complications were observed.Disposition number one the patient will be transferred to the floor. number two he will be kept at least overnight. Number three he will be taught drain care. Number four he will go home with the drain in place. Number five he may require a fistulogram in the future. Doctor kester signing out. *
55 points
1- Proofread and format the supplied text of Operative Report. Using the guidelines, transcription rules and report format . Doctor benard kester here. It’s 11 14 and I’m dictating a report an operative report on benjamin engelhart. His id number is 112592. His date of birth is 10 5 age 46 sex male. His date of admission is today 11 14 and the date of procedure is also today 11 14. Admitting physician benard kester, md, general surgery, surgeon same. Assistant jason wagner pac. Circulating nurse jimmy dale jet, rn. Preoperative diagnosis acute appendicitis. Postoperative diagnosis perforated appendicitis. Operative procedure number one laparoscopic appendectomy number two placement of right lower quadrant drain. Anesthesia general endotracheal tube anesthesia Specimen removed one necrotic appendix Iv fluids 17 hundred millilitres crystalloid estimated blood loss ten millilitres urine output 300 millilitres. Complications none. Indications this gentleman is a 46 year old caucasian male with a three day history of abdominal pain, however, over the past 24 hours his pain has located to the right lower quadrant and caused a significant amount of anorexia. He presented to the emergency department. Ct scan of abdomen and pelvis revealed acute appendicitis. Labs showed a wbc count of 13. The laparoscopic appendectomy procedure was explained along with the risks, benefits, and possible complications. Patient voiced his desire to proceed. Patient was started on preop gentamiacin. Description of procedure the patient was identified times two in the preoperative holding area. A final time out was held with the nursing service, anesthesia, and the surgical service during which the patient’s id was confirmed, and his surgical site was initialed. He was given perioperative antibiotics. He was taken back to the operating room and placed in the supine position. General et anesthesia was induced. Scds were placed on his lower extremities. His left arm was tucked at his side. A foley catheter was placed. His abdomen was shaved, prepped with betadine solution, and draped in the usual standard fashion. A small semicircular infraumbilical incision was made and carried down through the subcutaneous tissue to the level of the fascia. The fascia was grasped on either side and incised. A kelly clamp easily inserted into the abdomen. Stay sutures made of vicril were placed on either side. A hasson trocar was placed and pneumoperitoneum was easily achieved. In the left abdomen, a ten mm port was placed in the left mid abdomen, and a five mm port was placed in the left lower quadrant. Inspection of the right lower quadrant revealed a significant amount of adhesions from the small bowel trying to wall off this perforated appendix. Milky purulent exudate was noted in the surrounding area. The small bowel was carefully peeled off the right lower quadrant sidewall. There was fibrinous exudate. The vermiform appendix was identified. It was necrotic and perforated in appearance. The cecum was mobilized by taking down the lateral attachments laterally. The adhesions of the terminal ileum into the pelvis were significant. Attempts were not made at this time to free them. There was no evidence of obstruction. The base of the appendix was identified and dissected free. A stapler loaded with a blue load was used to transect the base however, again, the inflammation extended to the level of the cecum. The cecum itself was also inflamed. The remainder of the mesoappendix was divided with an endo gia loaded with a white load. The appendix was placed in an endo catch bag and brought out through the umbilical port site and sent to pathology for routine processing. Inspection of the right lower quadrant, area irrigated copiously. There was no further evidence of purulent exudate. The appendiceal stump remaining did appear to be inflamed however, it was not bleeding. There was also some fibrinous exudate in the area. Consequently, i felt we had two options. we either perform a right hemicolectomy, though given the extent of the adhesions in the pelvis, this would likely require a laparotomy, or we place a drain with antibiotics, possibly controlling this fistula until the inflammation resolves. Hopefully it will heal on its own spontaneously. Consequently, we placed a 19 french round blake drain in the right lower quadrant and brought it out through the left lower quadrant 5 millimeter port site. It was secured to the skin using a vicril suture. The pneumoperitoneum was then desufflated. The fascia of the umbilical port site was closed with two oh vicril that had been previously placed. All wounds were anesthetized with point 5 percent marcaine solution. The wounds were copiously irrigated. Skin edges approximated using 4 O monocril. The wounds were then dressed with betadine spray and steristrips. A drain sponge was placed around the drain. The foley catheter was removed. The patient was awakened extubated and taken to par in stable condition, having tolerated the procedure well. No complications were observed.Disposition number one the patient will be transferred to the floor. number two he will be kept at least overnight. Number three he will be taught drain care. Number four he will go home with the drain in place. Number five he may require a fistulogram in the future. Doctor kester signing out. *
55 points