Operation notes help

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Posts: 7
Joined: Sat Feb 11, 2006 6:23 pm
Location: UK

Operation notes help

Postby Samuria » Thu Aug 03, 2006 6:03 pm

6 x 6 parumblical hernia, reducible.
Slightly tender.
Otherwise abdomen SNT (soft non-tender)
No organmegaly (enlargement of the organs) no masses
Bowel sounds √

RS (Respiratory system): Air entry on left but reduced on right.
Breath sounds vesicular.
No wheeze or crackles.

CN (Central Nervous System): heart sounds 1 + 11 + 0
Neuro – intact. GCS (Glasgow coma scale) 15/15

Huge irreducible Para Umbilical Hernia- proceeded.

DIFFICULT (then the standard abbreviation for ‘because of’
Of LA!! Pain + especially near end
Irreducible omentum resected (IVS){type of staples used}
Herniotomy (CVS) {type of staples used}– congested + sac.
Mesh plug introduced into defect over peritoneum

Rectus sheath closed over mesh
2nd layer “ “ over 1st layer

IVS {type of sutures used} fat
Dexon subcutaneously

Can any one tell me what all this means? It’s a operation report from a hernia but what does the air entry on left mean and is it normal to test for the Glasgow coma scale? She did have problems with her heart which dropped to 38 bpm.

What do the heart sounds mean 1 + 11 + 0

Should we be worried by any of these ?

Dr. Tino Anthony Solomon
Medical Doctor
Posts: 50
Joined: Fri Aug 18, 2006 12:34 pm
Location: UK

Postby Dr. Tino Anthony Solomon » Thu Aug 24, 2006 4:52 pm

Hello there,

Your post is of a surgeon's pre-operative and operative notes. These are documented every time a patient is seen as a record of who attended the patient, when, where and the relevant findings. If a decision is made to treat the problem surgically, then an operative note detailing the procedures performed and including post-operative instructions is essential both for those looking after the patient (who may not have been present at all stages of the consultation and treatment) and medico-legally in case a complication arises.

The first paragraph describes the findings on abdominal examination and is self explanatory. The ability to reduce a hernia is important. (Hernia = the protusion of an organ or tissue through an abnormal opening usually due to a weakness in the tissue through which it protudes). The reducibility of the hernia essentially means that it is not incarcerated, that is, it can be pushed back and thus is less likely to have its blood supply cut off, although I am slightly confused as the operative notes state an irreducible hernia. A soft, non-tender abdomen excludes an infective or inflammatory reaction in the abdomen or peritoneum (a lining covering the abdominal cavity) causing a peritonitis which can be triggered by any surgical problem in that area and would require urgent surgery to prevent the spread of infection and organ shutdown.

The respiratory and cardiovascular systems are routinely examined prior to any surgery as they are major determinants in the overall health status of the patient. They can be used to help decide whether the concerned subject is fit enough to withstand the stresses of surgery and an anaesthetic. The 1+11+0 simply denotes that the first and second heart sounds were heard with no additional unusual sounds. The conclusion is that the heart sounds were normal at the time of examination.

I have never come across the Glasgow Coma Scale being tested pre-operatively simply because the ability to communicate alone gives one a maximum score. It is only used in the UK as a marker of consciousness in people with head injuries or any condition affecting the conscious state of a patient e.g. infection or metabolic disturbances.

The operative note details the procedure performed which seems to have occurred without any problems in this case. The only detail I note is missing is the post-operative instructions which can enhance or delay recovery if followed or not adhered to. The most important point to take from this is that the patient's examination was essentially normal and operation at the time of surgery a success. Hope this is of some help to you.

Dr Tino Solomon
BSc (Hons) Infection, MB BS
SHO, Surgery

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