Brief Or Note - 의학 (Medicine)

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====== Brief Or Note ======

<Operation note>
  -  The name of operation
  -  Operators
  -  Preoperative diagnosis
  -  Postoperative diagnosis
  -  Anesthesia
  -  operation fingind and procedures

====Cone knife Bx ]====
  -  Lithotomy position was made.
  -  Pelvic examination was done.
  -  Cone knife Bx. followed (by electrocauterization or hemostatic suture) was done.
  -  EBL was minimal.
  -  A piece of gauze was inserted into the vaginal cavity.

==== C-sec ]====
  -  A Pfannenstiel's incision was (including old scar revision) made.
  -  Entering the abdominal cavity, the uterus  was enlarged to       size.
  -  Low flap transverse Cesarean section was  done.
  -  A living male baby weighing  gm with  APGAR score of 1'- , 2'-  (BPD  cm) was  delievered in LOT(OA, SA) position at    :   PM on 20    .    .  Soonlater, a placenta weighing   gm was spontaneously expelled, of which finding was grossly  normal.
  -  On the manual exploration, both ovaries and tubes were grossly normal.
  - ( Bilateral tubal ligation with modified Pomeroy's method was done.)
  -  Anatomically repaired with Vicryl, silks and monosyn. (Dexon : Y )
  -  EBL was about 1000ml. (cf. NSVD : 400ml)
  -  Neither gauze nor drain was inserted.

====D & E]====
  -  Lithotomy position was made.
  -  Pelvic examination was done.
  -  A sound was passed through the cervical os to 8cm in depth.
  -  Dilatation of cervical os with Hegar's dilatator and evacuation was done.
  -  Necrotized conceptal tissue measuring about 100gm was evacuated.
  -  EBL was minimal.
  -  2 pieces of gauze were inserted into the vaginal cavity.

====Diagnostic laparoscopy ]====
  -  Lithotomy position was made.
  -  A 1cm vertical (or horizontal) incision was  made in the skin of the lower umbilical depression.
  -  A verres needle was inserted into the abdominal cavity and the abdomen was insufflated with CO2 gas of about 2 liters.
  -  After removal of verres needle, the trocar of the laparoscope was inserted.
  -  The 2nd. 3rd and 4th punctures were made in the low abdomen for operative laparoscopic devices.
  -  Entering the abdominal (or peritoneal) cavity, the uterus was grossly normal. Both ovaries were grossly normal. Bilateral tubal obstruction and hydrosalpinx of distal tube were noted.
  -  After removal of laparoscope, CO2 gas was extracted.
  -  Anatomically repaired with silks.
  -  EBL was minimal.
  -  Neither gauze nor drain was inserted.

====Ectopic pregnancy - explo]====
  -  A lower midline abdominal skin incision  was made.
  -  Entering the abdominal cavity, the uterus was slightly enlared. Rt. tubal pregnancy, ampular portion, abortive type was noted, which was measuring   x  x  cm  in size. Bilateral ovaries and left tube was grossly normal(free     blood and blood clots were accumulated in about   ml amount.)
  - Rt. salpingectomy including ectopic mass was done.
  - Lt. tubal ligation by modified Pomeroy's method was done.
  - On the manual exploration, the liver, stomach, and intestines were grossly normal.
  - Anatomically repaired with vicryls and silks.
  - EBL was about 1500ml.
  - Neither gauze nor drain was inserted.

==== RAH with BPLND, or Type I, II, Ext.hysterectomy ]====
  -  A low midline abdominal skin incision (extended above the umbilicus) was made.
  -  Entering the abdominal cavity, the uterus was normal in size and shape. Bilateral tubes and ovaries were grossly normal in shape and size.
  -   Paraaortic lymph node biopsy was done and sent to frozen section of which finding was free from tumor.
  -  Bilateral ureter identification was done, and it was grossly normal.
  -  Radical abdominal hysterectomy (Type I Extended hysterectomy) with bilateral salpingoophorectomy was done.
  -  Pelvic lymph node dissection of both side were done, of which finding were free from tumor.
  -  Vaginal vault was partially opened, and inserted penrose vaginal vault drain. Vaginal vault was completely closed.
  -  On the manual exploration, the liver, stomach, and intestines were grossly normal.
  -  Anatomically repaired with Vicryl, silks and nylon.
  -  EBL was about 1000ml.
  - Hemovac drain was inserted into retroperitoneal space and no gauze was packed.

==== Reversal operation ]====
  -  A Pfannenstiel abdominal skin incision was made.
  -  Entering the abdominal cavity, the uterus and both ovaries were grossly normal in size and shape. Previous bilateral tubal ligation with ring was noted.
  -  Microscopic bilateral tubal end to end reanastomosis from isthmic to ampullar portion was performed. The remnants of tubes were   - 0cm in Left and   - 0cm in right.
  -  Chromopertubation was performed and good patency of both tubes was noted.
  -  Anatomically repaired with Vicryl, and nylons.
  -  EBL was about minimal.
  -  Neither gauze nor drain was inserted.

====TAH with BSO ]====
  -  A lower midline skin incision was made.
  -  Entering the abdominal cavity, uterus was slightly enlarged to    weeks sized.  Both tubes and ovaries were grossly normal in shape and size.
  -  Total abdominal hysterectomy with bilateral salpingoophorectomy was done.
  -  Vaginal vault was completely closed.
  -  (On the manual exploration, the liver, stomach, and intestine were grossly normal.)
  -  Anatomically repaired with vicryl, silks, and nylons.
  -  EBL was about 600ml.
  -  Neither gauze nor drain was inserted.

====Tuboplasty ]====
  -  Lithotomy position was made.
  -  A curvilinear incision was made in the skin of lower umbilical depression.
  -  A verres needle was inserted the abdominal cavity and the abdomen was insuflated with CO2 gas of about 2 liters.
  -  After removal of verres needle, the trocar of the laparoscope was inserted.
  -  Laparoscope was inserted into the abdominal cavity, the uterus was grossly normal in size and shape and both ovaries were alsogrossly normal, but bilateral tubal obstruction was noted.
  -  After changing to supine position, a Pfannenstiel abdominal skin incision was made.
  -  Entering the abdominal cavity, the uterus was grossly normal. Both ovaries were also grossly normal. Bilateral tubal obstruction was noted. Chromopertubation revealed bilateral tubal obstruction at isthmic portion of each tubes.
  -  Segmental resection of both tubes at the obstructed portions were carried out. Tubal ostia were identified and their patency were    confirmed by passing the dye.Microscopic  reanastomosis of each tube was done.
  -  On the manual exploration, the liver, stomach and intestines were grossly normal.
  - Anatomically repaired with Vicyl, silks, and nylon.
  -  Neither gauze nor drain was inserted.

==== VH & A-P repair ]====
  -  Lithotomy position was made.
  -  Pelvic examination was done. and its findings were as follows ;
  -  Vaginal hysterectomy was done.
  -  Anterior and posterior colporrhaphy was done.
  -  Anatomically repaired with CCGs.
  -  EBL was about 200ml.
  -  Vaginal vault drain was inserted.
  -  A roll of vaseline packing was inserted into the vaginal cavity.

====TVT(tension of free vaginal tapering)====
  -  Lithotomy position was made
  -  Pelvic examination was done 
  -  bladder filling was done
  -  Under the cystoscopy, visualization and tension free vaginal tapering was done.
  -  Anatomical repaired with silk.
  -  EBL was done.
  -  Neither gauze nor drain was inserted.

* Expire note
사망 장소 : 아주대학교 의료원
사망시간 : Year. month. day. time
직접 사인:
중간 선행사인
간접 사인
상기 환아는 ......................해서 사망했다.
P/Ex  pupil : full dilatation s reflexes
       heart sound : none
       respiratory : none
       femoral , carotid pulse : none
       anal tone : no reflex
EKG  flat
    EKG flat 한 recording 한 것 붙인다
                                             sign
Termination note
<  :   AM>
시간별로 시행한것 기록 (cytotec, nalador 등등0
<termination>
A dead female baby.....................( 제왕절개 4번 기록)
00 MD 초음파로 placenta tissue 자궁 내 남아있지 않음을 확인, 만약 vaginal bleeding 소견 보여 gauze packing함
사진 붙이고   
       no fetal abnormal
       no heart beat
       no breathing sound
       no fetal movement

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