Medical Specialty:
Gastroenterology
Sample Name: Laparoscopy & Laparoscopic Appendectomy
Description: Diagnostic laparoscopy and laparoscopic appendectomy. Right lower quadrant abdominal pain, rule out acute appendicitis.
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Right lower quadrant abdominal pain, rule out acute appendicitis.
POSTOPERATIVE DIAGNOSIS: Acute suppurative appendicitis.
PROCEDURE PERFORMED:
1. Diagnostic laparoscopy.
2. Laparoscopic appendectomy.
ANESTHESIA: General endotracheal and injectable 1% lidocaine and 0.25% Marcaine.
SPECIMEN: Appendix.
COMPLICATIONS: None.
BRIEF HISTORY: This is a 37-year-old Caucasian female presented to ABCD General Hospital with progressively worsening suprapubic and right lower quadrant abdominal pain, which progressed throughout its course starting approximately 12 hours prior to presentation. She admits to some nausea associated with it. There have been no fevers, chills, and/or genitourinary symptoms. The patient had right lower quadrant tenderness with rebound and percussion tenderness in the right lower quadrant. She had a leukocytosis of 12.8. She did undergo a CT of the abdomen and pelvis, which was non diagnostic for an acute appendicitis. Given the severity of her abdominal examination and her persistence of her symptoms, we recommend the patient undergo diagnostic laparoscopy with probable need for laparoscopic appendectomy and possible open appendectomy. The risks, benefits, complications of the procedure, she gave us informed consent to proceed.
OPERATIVE FINDINGS: Exploration of the abdomen via laparoscopy revealed an appendix with suppurative fluid surrounding it, it was slightly enlarged. The left ovary revealed some follicular cysts. There was no evidence of adnexal masses and/or torsion of the fallopian tubes. The uterus revealed no evidence of mass and/or fibroid tumors. The remainder of the abdomen was unremarkable.
The patient tolerated the procedure well. She was extubated following the procedure, returned to Postanesthesia Care Unit in stable condition. She will be admitted to General Medical Floor and she will be followed closely in the early postoperative course.
Keywords: gastroenterology, lower quadrant, diagnostic laparoscopy, acute appendicitis, laparoscopic appendectomy, abdomen, appendectomy, laparoscopy, appendix, suprapubic,