Premier Surgery Center of Santa Maria
816 East Enos Drive, Suite B ♦ Santa Maria, CA 93454 ♦ (805) 347-7813
OPERATIVE REPORT
PATIENT NAME:
MEDICAL RECORD NUMBER:
PATIENT DATE OF BIRTH:
DATE OF SURGERY:
ZOOK, REBECCA A.
0001251
06/16/1964
February 17, 2010
SURGEON:
ASSISTANT:
ANESTHESIOLOGIST:
ANESTHESIA:
DAVID STERLING, D.P.M.
NONE
JAMES JUSTICE, M.D.
LOCAL WITH MONITORED ANESTHESIA
CARE
PREOPERATIVE DIAGNOSIS:
1. Mass, anterior lateral aspect, Left Ankle.
POSTOPERATIVE DIAGNOSIS:
1. Mass, anterior lateral aspect, Left Ankle.
OPERATIVE PROCEDURE:
1. Excision of mass, anterior lateral aspect, Left Ankle.
ANESTHESIA USED: Local anesthesia, with monitored anesthesia care, consisting of
approximately 9 cc of a 50/50 mixture of 0.5% Marcaine plain plus 1% Xylocaine plain. Added
to this was 1 cc of Decadron.
HEMOSTASIS: Pneumatic ankle tourniquet, Left lower extremity, inflated to 250mmHg.
ESTIMATED BLOOD LOSS: Less than 5.0 cc.
COMPLICATIONS: None.
FINDINGS AND PROCEDURE: The patient was brought into the operating room and placed
on the operating room table in the supine position, and the ankle tourniquet was applied to the
left side. Via the use of monitored anesthesia, a local anesthetic was administered to the surgical
site as noted above.
Page 1 of 3
Premier Surgery Center of Santa Maria
816 East Enos Drive, Suite B ♦ Santa Maria, CA 93454 ♦ (805) 347-7813
OPERATIVE REPORT
PATIENT NAME:
MEDICAL RECORD NUMBER:
PATIENT DATE OF BIRTH:
DATE OF SURGERY:
ZOOK, REBECCA A.
0001251
06/16/1964
February 17, 2010
Once adequate anesthesia was achieved, the foot and ankle were then prepped and draped in the
usual sterile manner. An Esmarch bandage was applied from toes to tourniquet on the left side,
and the pneumatic tourniquet was inflated to 250mmHg for hemostasis. The surgery then began.
Attention was first directed to the anterior lateral aspect of the left ankle where a 3.0 incision was
made. The incision was made in the relaxed skin tension line. The incision was deepened via
the use of sharp and blunt dissection, taking care to note and avoid all vital structures. All
bleeders were cauterized. The incision was carried down to the suspected mass, which was
identified. Via the use of blunt dissection, this mass was excised and sent to pathology for
examination. The area was irrigated with copious amounts of sterile saline solution. No other
suspect tissue was identified in the area. The skin edges were then coaptated closed via the use
of 5-0 nylon suture. The area was then dressed with Adaptic, gauze, and Kling with mild
compression. The tourniquet was then released and circulation to all digits was noted to be
within normal limits.
The patient was then transferred from the operatory room to the recovery room in apparent
satisfactory postoperative condition. There were no complications. Blood loss was estimated to
be less than 5.0 cc. It was felt the patient left the operatory room in a much improved condition.
ADDENDUM:
It must be noted that the observation for the intermediate dorsal cutaneous nerve was performed,
and this was not observed in the incisional site area.
_________________________
David Sterling, D.P.M.
DS/mes
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Premier Surgery Center of Santa Maria
816 East Enos Drive, Suite B ♦ Santa Maria, CA 93454 ♦ (805) 347-7813
OPERATIVE REPORT
PATIENT NAME:
MEDICAL RECORD NUMBER:
PATIENT DATE OF BIRTH:
DATE OF SURGERY:
ZOOK, REBECCA A.
0001251
06/16/1964
February 17, 2010
D: 02/17/10
T: 02/17/10
Tracking #: CC01456
cc:
David Sterling, D.P.M.
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