Operative Report on Benjamin Engelhart

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OPERATIVE REPORT

Patient Name: Benjamin Engelhart

Patient ID: 112592 DOB: 10/05/1965 AGE: 46 SEX: M

Date of Admission: 11/14/2012

Date of Procedure: 11/14/2012

Admitting Physician: Bernard Kester, MD

Surgeon: Bernard Kester, MD

Assistant: Jason Wagner, PAC

Circulating Nurse: Jimmy Dale Jett, RN

Preoperative Diagnosis: Acute Appendicitis

Postoperative Diagnosis: Perforated Appendicitis

Operative Procedure:
1. Laparoscopic appendectomy.
2. Placement of right lower quadrant drain.

Anesthesia: General endotracheal tube anesthesia.

Specimen Removed: One necrotic appendix.

IV Fluids: 1700 mL crystalloid.

Estimated Blood Loss: 10 mL.

Urine Output: 300 mL.

Complications: None

INDICATIONS: This gentleman is a 46-year-old Caucasian male with a 3 day history of abdominal pain. However, over the past 24 hours his pain is 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. Lab showed a WBC count of 13. The laparoscopic appendectomy procedure was explained along with the risks, benefits and possible

(Continued)
Operative Report

Patient Name: Benjamin Engelhart
Patient ID: 112592
Date of Procedure: 11/14/2012
Page 2

complications. The patient 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. A final time out was held with the nursing service, anesthesia and the surgical service during which the patients’ ID was confirmed and his surgical site was initialed. He was give perioperative antibiotics; he was taken back to the operating room and placed in a supine position. General ET anesthesia was induced SCDs were placed on his lower extremities. His left arm was tucked to his side. A Foley catheter was placed. His abdomen was shaved prepped

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