Medical Case Report: Sadako Sasaki
OPERATIVE REPORT
Patient Name: Sadako Sasaki
Patient ID: 110456 DOB: 4/09 Age: 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 …show more content…
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 white lower infintubular extravagations.
Under
OPERATIVE REPORT
Patient Name: Sadako Sasaki
Patient ID: 110456
Date of Procedure: 12/22
Page 2
fluoroscopy, a 6 french 24 cm. double J uteral stent placed over this wire with pearling in the renal pelvis and in the bladder. The bladder was drained and an 18 french uteral catheter was placed.
Vaginoscopy was then performed with a rigid cystoscope, with no intravaginal abnormalities noted. This was performed for significant vaginal bleeding following trauma at a time not expected for men seen by this patient. Blood was noted to become leaking slowly from the cervical s. The scope was then removed and the patient awakened in the operating room. She was then returned to the packu in stable condition. There was no complications. Rosemary Bumbak out.
_________________________
Rosemary Bumbak, MD
Patient Name: Sadako Sasaki
Patient ID: 110456 DOB: 4/09 Age: 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 …show more content…
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 white lower infintubular extravagations.
Under
OPERATIVE REPORT
Patient Name: Sadako Sasaki
Patient ID: 110456
Date of Procedure: 12/22
Page 2
fluoroscopy, a 6 french 24 cm. double J uteral stent placed over this wire with pearling in the renal pelvis and in the bladder. The bladder was drained and an 18 french uteral catheter was placed.
Vaginoscopy was then performed with a rigid cystoscope, with no intravaginal abnormalities noted. This was performed for significant vaginal bleeding following trauma at a time not expected for men seen by this patient. Blood was noted to become leaking slowly from the cervical s. The scope was then removed and the patient awakened in the operating room. She was then returned to the packu in stable condition. There was no complications. Rosemary Bumbak out.
_________________________
Rosemary Bumbak, MD