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Practice Case Studies Sana ay PROGRESS NOTES-PATIENT 5 DATE NOTE 1/5 The patient is admitted for LAVH because of postmenopausal bleeding. She has also had left lower-quadrant pain. General condition is good. Operative Note: Preop: Possible adenocarcinoma of the endometrium Postop: Same, pathology pending Procedure: LAVH Anesthesia: General FINDINGS: Tubes and ovaries were within normal limits. Uterus is submitted for pathologic examination. Estimated blood loss is 300 cc. Called back to the RR for decrease in blood pressure and decreased urine output. The patient was found to have abdominal distention as well. The patient was given 3 units of blood and taken back to the operating room for evaluation of postoperative hemorrhage. OPERATIVE NOTE: 1/5 Preop: Postop hemorrhage Postop: Accidental laceration of epigastric artery, acute blood loss anemia Procedure: Repair of bleeding vessel via laparoscope Anesthesia: General EBL: 1,500 to 2,000 mL of blood The patient was admitted to the ICU following surgery where we will monitor her progress throughout the night. 1/6 Patient is doing well today. The BP is stable, urine output good-diuresing well, wound clean and dry, healing well. Will transfer her to the surgical floor. The patient is stable, offers no complaints. Will discharge to home. 1/7 60
PHYSICIAN'S ORDERS-PATIENT 5 DATE ORDER 1/5 Admit for LAVH Type and cross 4 units of blood, CBC Prepare for vaginal hysterectomy Synthroid 0.200 mcg daily NPO Demerol 75 mg Atropin 0.4 mg preop Postop, transfer patient to ICU D5NSS 125 cc/h Transfuse three units PRBC Demerol 75 mg IM q. 4 hours as need for pain Ancef 500 mg q. 6 hrs x3 doses CBC q. 4 hrs, Strict I & O Transfer to floor; please get patient OOB and provide liquids at bedside Continue I & O CBC this a.m. then tomorrow a.m. D/C IV after 6:00 p.m. if stable Discharge to home 1/6 1/7 Practice Case Studies 61
Practice Case Studies OPERATIVE REPORT PATIENT 5 DATE: 1/5 PREOPERATIVE DIAGNOSIS: Possible adenocarcinoma the endometrium POSTOPERATIVE DIAGNOSIS: Pending pathology report OPERATION: Laparoscopic assisted vaginal hysterectomy with pelvic cytology ANESTHESIA: General OPERATIVE PROCEDURE: With the patient under satisfactory general anesthesia in the semilithotomy position, she was prepped and draped in the usual fashion for a laparoscopic and vaginal procedure. Through an infraumbilical incision, a Veress needle was inserted to establish a pneumoperitoneum using a high-flow insufflator with CO, gas, maintaining 15 mm of pressure. It was then followed by insertion of a 10-mm trocar into the infraumbilical incision, followed by the laparoscope with laparoscopic examination having been done with findings described above. After transillumination of the abdomen noting vessels, an incision was made in the skin and 12-mm trocars and sleeves were inserted into the right and left lower quadrant. After having inserted the 12-mm sleeves, an endogauge was inserted into Channel A and levels of the right and left tubo-ovarian ligaments and broad ligaments were measured. An endo-GIA was then inserted into Channel A, followed by endo-GIA of Channel B, amputating the attachments of the tubes and ovaries and the broad ligaments. The remaining attachments of the broad ligaments and the round ligaments were picked up with endo-GIA staplers on both sides. A grasper was then inserted on Channel A, and the bladder reflection was picked up and elevated. It was then opened with endoshears, and using hydrodissection and ultrasonic scalpel, a bladder flap was created by sharp and blunt dissection with the scalpel. The dissection was carried down to the surface of the anterior lip of the cervix, which was noted to be smooth and free of adhesions. This was extended down past the cervicovaginal junction with identification of the tenaculum in the vagina. The grasper was then replaced on the right cornua and traction placed on the uterus, exposing the right cardinal ligaments, which was then placed on traction and using the scalpel probe, skeletonization of the uterine arteries with exposure of the arteries was done automatically. The peritoneum was then dissected down past the uterosacral ligament insertion. After complete skeletonization of the uterine arteries was done, an endo TA-30 stapler was placed on the uterine arteries and the pedicle was cut off with the scalpel. There were no bleeding points noted. The grasper was then removed and inserted into Channel B, and the left cornua of the uterus was picked up and placed on traction. The left cardinal ligaments and uterine arteries were then picked up and skeletonized, and complete exposure and dissection was done with visualization and identification of the arteries. The fragments of paravesical tissue were dissected off with the scalpel without traumatizing the bladder, which had previously been filled up with methylene blue and no spillage of the dye was noted during dissection of the uterus. An endo TA-30 was then inserted in Channel A and linear staples were placed on the uterine arteries, on the left uterine artery and the cardinal ligament pedicles. The pedicle was then cut off with the scalpel. A second line of staples was then placed below the first line, taking care not to include the dome of the bladder without entering the vagina, and the pedicle cut off with the scalpel. There was a change in color of the uterus from pink to gray, indicating complete obliteration of blood supply. The staple lines on the infundibular pelvis ligaments were then inspected and this was found to be adequate. At this time the laparoscopic procedure was temporarily stopped and attention was then paid to the vaginal portion of the procedure, releasing the pneumoperitoneum that had been established for the laparoscopy. The cervix was exposed and picked up on the anterior a posterior lip with Lahey 62
Practice Case Studies KONSEKVEN PATHOLOGY REPORT PATIENT 5 ven DATE: 1/5 SPECIMEN: Uterus CLINICAL DATA: PREOPERATIVE DIAGNOSIS: Adenocarcinoma of endometrium POSTOPERATIVE DIAGNOSIS: Same GROSS DESCRIPTION: The specimen is labeled "Uterus." Submitted uterus with cervix attached. The specimen has previously been partially opened. It measures 9 x 5 x 3 cm and weighs 58 g. The body of the uterus appears to be symmetrical. On section, the endocervix and ectocervix appear essentially normal. The endocervical canal likewise appears normal. The endometrial cavity is involved by a polypoid tumor mass chiefly in the right cornual area and measuring 3 cm in greatest diameter. The tumor appears to superficially penetrate the myometrium. The specimen will be further sectioned following fixation. A and B are sections of cervix; C, D, E, F, G, and H are full-thickness section of tumor; section I is a full-thickness section from grossly uninvolved tissue. MICROSCOPIC DESCRIPTION: DIAGNOSIS: Adenocarcinoma, intermediate grade, of endometrium. Chronic cervicitis COMMENT: The tumor penetrates approximately 0.4 cm into a total myometrial thickness of 1.5 cm. 64
DESA OPERATIVE REPORT-PATIENT 5 DATE: 1/5 PREOPERATIVE DIAGNOSIS: Postoperative hemorrhage POSTOPERATIVE DIAGNOSIS: Bleeding from right epigastric artery OPERATION: Emergency diagnostic laparoscopy with repair of epigastric artery and blood transfusion ANESTHESIA: General OPERATIVE INDICATIONS: Estimated blood loss 1,500 to 2,000 mL of whole blood OPERATIVE PROCEDURE: There was liquid and clotted blood in the abdominal cavity, approximately 1,500 to 2,000 mL, with blood coming from the puncture in the right lower quadrant, apparently from an accidental laceration of the right epigastric artery. The pedicles were inspected in the pelvis, and these were found to be dry. With the patient under satisfactory general anesthesia, after having been transfused three units of packed RBCs, she was taken to the operating room and an emergency laparoscopic examination was carried out by opening the previous stab wounds with irrigation of the abdominal and pelvic cavity, evacuating approximately 1,500 to 2,000 mL of liquid and clotted blood. Exposure of the pedicles of the infundibulopelvic ligament on both sides and the uterine arteries and the vaginal vault revealed them to be dry. There was no bleeding anywhere else in the pelvic cavity. A puncture was found in the epigastric artery. Using an endoclosed needle through which a #0 Vicryl ligature was attached, the artery was repaired, stopping the bleeding point. This was verified by inspection with the laparoscope. After this was accomplished, the fascia was once again closed with endoclosed needle and #0 Vicryl suture on the right lower quadrant. The left lower quadrant was left open, and a Jackson-Pratt drain was inserted into the incision and placed in the pelvis for drainage. The patient was then removed from the Trendelenburg position after ascertaining that vital signs were stable. The CO, was released gradually. All instruments were removed, and subcuticular closure of the stab wounds was done using # 4-0 Monocryl sutures. At the termination of surgery the patient's vital signs were stable. She, however, remained hypotensive with tachycardia with good urine output and was transfused an additional three units and transferred to the intensive care unit for postoperative care. De Spe LABORATORY REPORTS-PATIENT 5 HEMATOLOGY Normal Values 1/5 1/5 1/7 5.0 5.0 5.1 5.0 4.0 L 4.5 7.1 L 5.5 L 9.0 L 38 L 32 L 43 90 89 96 44 46 50 160 165 300 Specimen WBC RBC HGB HCT MCV MCHC PLT Results 1/5 5.2 089 4.2 L 7.9 L 39 L Practice Case Studies 97 48 170 4.3-11.06 4.5-5.9 13.5-17.5 41-52 80-100 31-57 150-400
Practice Case Studies HEMATOLOGY-PATIENT 5 Specimen WBC 9.2 RBC 4.6 HGB 10.1 L HCT 44 MCV 90 89 MCHC 44 46 PLT 160 165 Enter nine diagnosis codes and three procedure codes. PDX DX2 DX3 DX4 DX5 DX6 DX7 DX8 DX9 PP1 PR2 PR3 66 1/5 1/5 9.5 4.8 10.3 L 41 Results 1/5 9.8 5.1 11.0 L 45 97 48 170 Dow 1/7 9.7 5.2 12.1 L 44 96 50 300 - Normal Values 4.3-11.0 4.5-5.9 13.5-17.5 41-52 80-100 31-57 150-400