Manipulative Procedures Example 13

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Operative Report

  • Name: Abner Hodges
  • Service: Surgery
  • Hospital No.: 000031
  • Sex: Male
  • Age: 40
  • Race: White
  • Ward: W505
  • Date: 10/21/91

Surgeon: Dick Dixon, MD Assistant: Jim Jackson, MD
Anesthetist: R. Bop, MD

  • Name of Operation: Mediastinoscopy, sternal puncture biopsy
  • Pre-Operative Diagnosis:________________________
  • Post-Operative Diagnosis: Probable Hodgkin Disease or lymphoma
  • Operation Started: 8:30 am
  • Operation Ended: 9:50 am

Procedure in Detail:

The patient was anesthetized without complication. A nasotracheal tube was placed. The patient was prepped from the nipples to the chin region. A small lateral incision was placed just above the jugular notch. Dissection was carried down to the trachea. The peritracheal fascia was found to be fibrotic and adherent around the trachea, and it was impossible to burrow the mediastinoscope into this region. An approximately 2 x 3 cm firm, somewhat hard grayish lymph node was discovered in the pretracheal region, and excisional biopsies were taken of this node and sent or culture for fungus, tuberculosis, and for pathologic report. Good hemostasis was obtained. The patient was then closed using #3 nylon for the skin sutures. It was decided because of the presumption of good diagnostic material in the lymph node that bronchoscopy should not be attempted at this time. It was also felt that bronchoscopy could add significantly to the morbidity of the procedure, and the procedure was discontinued at this time. Before the patient was aroused from anesthesia a sternal bone marrow tap was done with good aspiration and no complications. Post-operative diagnosis: Probable Hodgkin disease or lymphoma. Estimated blood loss between 250 and 300 cc. Complications-None.

Dictated: 10/21/91
Date transcribed: 10/26/91