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Operating Room Write Up

Juan Dela Cruz assisted in an emergency appendectomy on Makisig Morales, a 16-year-old male who presented with acute appendicitis. The patient experienced right lower quadrant pain for five hours prior to admission. Physical examination at the emergency department revealed signs and symptoms consistent with acute appendicitis. Dr. Mamungay performed an emergency appendectomy under general anesthesia. The operation addressed Makisig Morales' diagnosis of acute suppurative appendicitis.

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Enrico Sapitula Del Rosario
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276 views

Operating Room Write Up

Juan Dela Cruz assisted in an emergency appendectomy on Makisig Morales, a 16-year-old male who presented with acute appendicitis. The patient experienced right lower quadrant pain for five hours prior to admission. Physical examination at the emergency department revealed signs and symptoms consistent with acute appendicitis. Dr. Mamungay performed an emergency appendectomy under general anesthesia. The operation addressed Makisig Morales' diagnosis of acute suppurative appendicitis.

Uploaded by

Enrico Sapitula Del Rosario
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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OPERATING ROOM WRITE UP

Name: JUAN DELA CRUZ Year/Section/Group: ____BSN 3-A___


Patient’s Name: MAKISIG MORALES Age: 16 Gender: MALE
Address: BRGY. SAPANG BATO, BAUANG LA UNION
Pre-op diagnosis: ACUTE APPENDICITIS
Post-op Diagnosis: ACUTE SUPPRATIVE APPENDICITIS STATUS
POST EMERGENCY APPENDECTOMY
Operation done: EMERGENCY APPENDECTOMY
Date of operation: SEPTEMBER 30, 2020 Type of Anesthesia: SAB
Time started: 8:30 AM Time Ended: 9:10AM
Surgeon:J. MAMMUNGAY Anesthesiologist: F. CORPUZ
Scrub Nurse: MRR. SILVA
History of the patient:

Five hours prior to admission, the patient experienced right lower quadrant pain characterized as
non- radiating, 8 in severity, aggravated by coughing and when changing position. The patient seek
medical consultation at LUMC Emergency Department. He was seen by Dr. Mamungay, and
physical examination done. Presenting signs and symptoms of acute appendicitis was noted. Hence,
admitted and for ‘E’ Appendectomy.

Discussion of the disease/condition/pathophysiology:

Note:

You discuss the disease entity of disease/ operation/


You can focus your discussion on the pathophysiology of the disease
through algorithm.

For example, your case tackles Appendicitis, you can search


the disease entity or focus on pathophysiology of this case.
Discussion of the operation done:

Discuss the operation done.

For instance the case above tackles acute appendicitis and the
operation is appendectomy.
You may generally discuss the operation which is appendectomy,
however in the actual setting, you discuss the operation performed
to
your respective patient.

Instruments: (separate sheet)


In this section, draw the instruments involved in this operation.

In this time, you may search on the required instruments


for this case which is appendectomy.

On the other hand, in the actual setting, you ONLY include


instrument that is used DURING your case.

For instance, the needed instruments for this case are surgical
scissors
(Mayo Curve, Mayo Straight, Metzembaum),
Richardson, Army Navy, Bobcock, Thumb and Tissue Forceps, AND, Adson
Forceps.

YOU MUST DRAW THE TIP OF THE INSTRUMENTS FOR BETTER IDENTIFICATION
OF.

Name and Signature of the Clinical Instructor: _______________________________________

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