GOODMEDICINE CLINIC
1 Provider Street • Anywhere, NY 12345-2345 • (101) 111-2222
PROVIDER: HENRY C. CARDIAC, M.D.; T.J. STITCHER, M.D.
Patient Record
INPATIENT HOSPITALIZATION Admitted: 06/19/YYYY Discharged: 06/20/YYYY
APPLE, JAMES
ADMITTING PROGRESS NOTE 06/19/YYYY
Patient admitted with acute appendicitis. Dr. Stitcher called in as
surgeon.
Henry C. Cardiac, M.D.
Henry C. Cardiac, M.D.
APPLE, JAMES
OPERATIVE REPORT 06/19/YYYY
PREOPERATIVE DIAGNOSIS: Acute appendicitis.
POSTOPERATIVE DIAGNOSIS: Acute appendicitis.
OPERATION: Laparoscopic exploration with appendectomy.
SURGEON: T.J. Stitcher, M.D.
PROCEDURE: Patient anesthetized with general anesthesia via endotracheal
tube. Abdomen prepped and draped in sterile fashion. Because of
patient's size (he is quite small) it was not possible to place
a catheter in the bladder. Patient was placed in Trendelenburg
position. Abdominal wall was palpated, no masses felt. Incision was made
below the umbilicus, and Verres needle inserted toward the pelvis. This
was tested with normal saline; when it appeared to be in the peritoneal
cavity, the abdomen was insufflated with 3 liters of $CO_2$. A 1/2 cm
camera was introduced through this opening. There was no evidence of
injury from the needle or trocar, and the area of the appendix was
visualized and some exudates and free fluid in the area noted. Under
direct vision, a 1/2-cm trocar was passed through the right edge of the
rectus sheath in the mid-abdomen. Using blunt and sharp dissection, the
appendix and cecum were mobilized. The mesoappendix was serially ligated
with hemoclips and then divided and the appendix freed to its base. The
base was identified by the fact it was supple and it lay at the
convergence of the tinea. A single 0 chromic suture was laced
approximately 1 cm distally, and then the appendix divided between and
through the 11 mm trocar. The abdomen was irrigated with normal saline,
and the contents aspirated. Skin closed with 4-0 Vicryl, and Benzoin and
SteriStrips applied. Estimated blood loss was 10 cc. Sponge and needle
counts were correct. Patient tolerated the procedure well and returned
to the recovery room awake and in stable condition.
T.J. Stitcher, M.D.
T.J. Stitcher, M.D.
APPLE, JAMES
DISCHARGE PROGRESS NOTE 06/20/YYYY
Patient was unremarkable postoperatively. Discharged 9 AM today.
Mother was given standard, written pediatric appendectomy discharge
sheet. Patient to be seen in the office of J.H. Cutdown, M.D., in 5 days
for postop follow-up.
T.J. Stitcher, M.D.
T.J. Stitcher, M.D.
