Answer: Operative Report Example 2

03/11/9 Expl. Lap.:

Large, fixed mass on posterior wall of fundus of stomach invading the spleen. Numerous nodes along lesser curvature of stomach. Some tumor studdings in left lobe of liver. Node was Bx'ed. Post-op Dx: Carcinoma of the stomach.

Comments:

The following points should be noted with respect to the operative record used in this illustration.

  1. A clinical history is presented. Sometimes this is not present. When it is, it can be very useful. For example, this clinical history indicated that the patient was admitted with symptoms possibly related to cancer: 60 lb. weight loss in 8 months.
  2. The clinical history indicates that one or more reports of a GI series should be present in the medical record. They should report a lesion in the fundus of the stomach.
  3. Other diagnostic reports mentioned in the clinical history include chest films and liver scan which did not indicate metastatic spread.
  4. The location of the primary site on the posterior wall of the fundus of the stomach is described.
  5. According to the surgeon, the mass was invading the spleen and was metastatic to the liver. It appeared to involve nodes along the lesser curvature of the stomach. This indicated that the mass had extended beyond its primary site.
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