OPERATIVE REPORT Patient Name: Benjamin Engelhart Patient ID: 112592DOB: 10/5Age: 46Sex: M Date of Admission: 11/15 Date of Procedure: 11/15 Admitting Physician: Bernard Caster, MD Surgeon: Bernard Caster, MD Assistant: Jason Wagner, PAC Circulating Nurse: Jimmy Dale Jet, RN Preoperative Diagnosis: Acute Appendicitis Postoperative Diagnosis: Perforated Appendicitis Operative Procedure: Laparoscopic Appendectomy Placement of right lower quadrant drain Anesthesia: General Endotracheal tube anesthesia Specimen Removed: One lacrotic appendix IV Fluids: 1700 ml Chrystaloid Estimated Blood Loss: 10 ml Urine Output: 300 ml
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Complications: None INDICATIONS: This gentlemen is 46 years-old Caucasian male with 3 days history of abdominal pain, however over past 24 hours his pain has located to the right lower quadrant and caused a significant amount of anorexia, he presented to the emergency dept. CT scan of abdomen and levis revealed acute appendicitis, lab showed a WBC count of 13, the laparoscopic appendectomy was explained along with the risks, benefits and possible complications. Patients voiced his desire to proceed. Patient was started on pre-op gentamicin. DESCRIPTION OF PROCEDURE: The patient was identified x2 in the preoperative holding area. Continue) OPERATIVE REPORT Patient Name: Benjamin Engelhart Patient ID: 112592 Date of Procedure: 11/15 Page 2 The final timeout was held with the nursing, anesthesia, and the surgical service during which the patient ID was confirmed and his surgical sight was initialed. He was given preoperative antibiotics. He was taken back to the operating room and placed in supine position. General ET anesthesia was induced. SED’s 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.
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