Hillcrest Case 7 Operative

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OPERATIVE REPORT

Patient: T.J. Moreno
Patient ID: 110497DOB: 02/15Age: 44Sex: M
Date of Admission: 10/09/2013
Date of Procedure: 10/09/2013
Admitting Physician: Patrick Keathley, MD Endocrinology
Surgeon : Dr. Max Hirsch, MD Orthopedics
Assistant: Markus Leroy Johnson PAC (Surgical assistant was used for soft tissue protection and retraction and also for maintaining reduction during temporary and permanent fixation use of surgical assistant was medically necessary, and to prove the safety and efficacy of the procedure.) Preoperative Diagnosis: Left hindfoot osteoarthritis.

Postoperative Diagnosis: Left hindfoot osteoarthritis.
Operative Procedure: 1) Triple arthrodesis . 2) Popliteal sciatic block placed by surgeon explicitly for postoperative pain management. Anesthesia: General by Chuck Delaney, MD. Condition during anesthesia, stable. Specimen Removed: Nine.

IV Fluids: See nurse’s notes.
Estimated Blood Loss: See nurse’s notes.
Urine output: See nurse’s notes.
Complications: None.
Postoperative condition: Stable

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OPERATIVE REPORT
Patient: T.J. Moreno
Patient ID: 110497DOB: 02/15Age: 44Sex: M
Page: 2

INDICATION: A 44 year old male with hindfoot osteoarthritis pain, who has failed conservative management after reviewing risks, benefits and alternatives, he has agreed to proceed with surgical management. Risks of delayed healing, non-healing and infection, nerve vessel tendon injury, ongoing pain and discomfort, procedure failure, need for revision surgery, and/or hardware removal noted. The fact that he will have a stiffed hindfoot noted. Patient’s questions were answered, and he was consented for the planned procedure. PROCEDURE IN DETAIL: The patient was taken to the operating room where general anesthesia was induced. Time out was taken indicating the appropriated site, procedure, and patient. Operative site was initialed, one gram of Ancef given IV. Popliteal...
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