OP cs1

Topics: Ureter, Kidney, Urinary bladder Pages: 2 (423 words) Published: April 15, 2015
OPERATIVE REPORT
Patient Name: Sadako Sasaki
Patient ID: 110456DOB: 4/09Age: Sex: F
Date of Admission: 12/19
Date of Procedure: 12/22
Admitting Physician: Rosemary Bumbak
Surgeon: Rosemary Bumbak
Assistant: Michael Gerard DO
Anesthesia:
Preoperative Diagnosis: Right renel urine leak
Postoperative Diagnosis: Same
Operative Procedures: 1. cystoscopy, vaginoscopy under anesthesia. 2. right retro-grade piliouretrogram. 3. right uteral stent placement. SEDATION: anesthesia

SPECIMEN REMOVED: none
PRE-OP MEDS: gentimyacin 80 mg, per I.V. leviquin 500 mg. I.V. prior to surgery. I.VI. fluids for anesthesia COMPLICATIONS: none
INDICATIONS: The patient in is the hospital, day 3. Following a fall from a ladder with result in a grade 4 renal laceration, with a minor right arm fracture. Per end. This was treated by Dr. Hartsch on day 1. Close per end. Patient had no serial hematocrits that showed no evidence of ongoing bleeding. Repeat CT imaging 2 days after trauma illustrated a continued urine leak. Due to this continued urine leak, a WBC count of 22,000 was noted. The patient was counseled on treatment options, to include continued observation or uteral stent placement. Ultimately he decided for the uteral stent placement. Then signed written and verbal consent forms, which are attached to his chart. DESCRIPTION OF OPERATION: The patient brought to the operating room with anesthesia provided. She was then placed in low lithotomy position on the table, and prepped and draped in the usual sterile fashion. A rigid cystoscope was advanced traumatically, entered the urinary bladder and no gross abnormalities were noted. The right ureter was cumulated under direct and fluoroscopic visualization to the renal pelvis with open ended uteral catheter placed over this. General retro-grade pileouteralgram revealed the normal ureter and renal pelvis with...
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