ORDER ON ADMISSION PRE-OPERATIVE ORDER

For routine OT patient

Diet: Normal/ Diabetic/ Soft/ Liquid. Diet: NPO from 12 AM till further order.

• Inj. TT • Please take informed written consent from the

1 amp I/M – STAT patient & patient’s legal guardian.
• Inj. TIG • Please shave & clean the operative area.
1 amp I/M – STAT • Please send the patient to OT on__ date__
• Tab. Alben-DS (400 mg) time__ with all documents.
0+0+1

*Continue Anti-Diabetic, Anti-hypertensive, Anti- *Mention about the morning dose of Anti-Diabetic,
asthmatic. Anti-hypertensive, Anti-asthmatic, Thyroid drug.
 POST-OPERATIVE ORDER ORDER ON 1st POD

Diet: NPO from 12 AM till further order. Diet: Sips of water followed by liquid the semi-solid then
normal/diabetic diet.
• Inf. Hartsol (1L) + 5% DNS (1L) + 5% DA (1L)
I/V @ 30 drops/min – Daily. • Inf. 5% DNS (1L)
• Inj. Ceftriaxone (1gm) I/V @ 10 drops/min.
1 vial – I/V after dilution ē N/S slowly over 10 mins – • Inj. Ceftriaxone (1gm) or Cap. Cefixime (400mg)
STAT & 12 hourly. I/V – 12 hourly or 1 + 0 + 1
• Inj. Metronidazole (100 ml) • Tab. Esoral (20mg)
1 bag – I/V @ 25 drops/min – STAT & 8 hourly. 1 + 0 + 1 – 30 mins – B/M
• Inj. Esomeprazole (40 mg) • Tab. Ketonic (10mg) or Cap. Anadol SR (100mg)
1 amp – I/V slowly – STAT & 12 hourly 1+1+1
• Inj. Pethidine (100mg) [IF PAIN] • Tab. Ceevit (250mg)
¾ amp or 75 mg - I/M – STAT [after giving Inj. 1+0+1
Vergon] • Tab. Multivitamin
• Inj. Vergon (12.5 mg) / Inj. Emistat (8mg) 1+0+1
1 amp – I/V – STAT. [before giving Inj. Pethidine] • Supp. Voltalin (50mg) or Supp. Anadol (100mg)
• Inj. Anadol (100mg) / Inj. Toradol (30mg) 1 stick – P/R – SOS
1 amp – I/M – STAT & 8 hourly
*Please monitor all the vitals routinely.
*Please give routine follow up 2 hourly.
*If any catheter/NG tube/ Drain tube/ Diabetic chart
(reflow) should be checked & keep record.
 ACUTE ABDOMEN INVESTIGATION FOR
ORDER On Admission ACUTE ABDOMEN
Diet: NPO till further order.

• Inf. Hartsol (1L) + 5% DNS (1L) + 5% DA (1L) 1. Plain X-ray abdomen in erect posture A/P
I/V @ 30 drops/min – Daily. view including both dome of diaphragm.
• Inj. Ceftriaxone (1gm) / Inj. Cefuroxime (1.5gm) 2. CBC
1 vial – I/V after dilution ē N/S slowly over 10 mins – 3. RBS
STAT & 12 hourly.
4. HBsAg (not routinely done)
• Inj. Metronidazole (100 ml) [optional]
5. Blood grouping & Rh typing
1 bag – I/V @ 25 drops/min – STAT & 8 hourly.
• Inj. Esomeprazole (40 mg)
6. ECG
1 amp – I/V slowly – STAT & 12 hourly 7. USG of Whole Abdomen
• Inj. Anadol (100mg) / Inj. Nalbun (20mg) [upper Abd] 8. Urine R/M/E
Inj. Toradol (30mg) [lower Abd] 9. Plain X-ray of KUB region (in case of lower
1 amp – I/M – STAT & 8 hourly abdominal pain)
• Supp. Voltalin (50mg) or Supp. Anadol (100mg) 10. S.Creatinine
1 stick – P/R – SOS 11. S. Electrolyte
12. S. Amylase
*Please monitor all the vitals routinely.
13. S. Lipase

*Continue Anti-hypertensive, Anti-asthmatic, Thyroid drug.

*Hold Anti-Diabetic drug.
 INVESTIGATION FOR Advice on discharge
PACU
1. নিয়নিত ঔষধ সেবি করববি
2. পনরনিত নবশ্রাি নিববি
1. CBC 3. প্রনতনিি পু নিকর খাবার খাববি ও ২.৫ - ৩ নিটার পানি
2. RBS পাি করববি
3. S.Creatinine
4. ____তানরবখ ছু টির কাগজ েহ োজজানর বনহজনবভাবগ সিখা
4. HBsAg
5. Chest X-ray করববি।
6. ECG
7. Urine R/M/E নহপ বাথঃ
8. Echo (above 40) ১ গািিা কুেু ি গরি পানিবত ৩-৪ চািচ Povidex নিনিবয় ১০-
9. S. Electrolyte
১৫ নিনিট কবর দিনিক ৩-৪ বার এবং প্রনতবার িি তযাবগর পর িিদ্বার
10. Blood grouping & Rh typing
নভনজবয় বেববি।
 OPERATION NOTE OPERATION NOTE
Laparoscopic appendicectomy Open appendicectomy
Name of the patient: Name of the patient:
Bed/ Cabin No.: Registration No.: Bed/ Cabin No.: Registration No.:
Date: Time: Date: Time:
Diagnosis: Recurrent Appendicitis. Diagnosis: Recurrent Appendicitis.
Indication: Recurrent Appendicitis. Indication: Recurrent Appendicitis.
Surgeon: Surgeon:
Aneasthesist: Aneasthesist:
Assistant: Assistant:
Anaesthesia: G/A Anaesthesia: G/A
Surgery Done: Laparoscopic appendicectomy. Surgery Done: Open appendicectomy.

Procedure & Findings: Procedure & Findings:

With all the aseptic precaution under general With all the aseptic precaution under general
anaesthesia in supine position, povidone painting anaesthesia in supine position, povidone painting
was done followed by proper draping. Then was done followed by proper draping. Abdomen was
umbilical port was made, gas was infiltered. Then open by a grid incision made. An inflamed and
other 2 port were made. Identification of appendix elongated appendix was found. Appendicular artery
was done, and base was ligated by 1/0 Vicryl, was ligated. Appendix was cut in its base and
appendix was excised. After proper hemostasis, ports appendicectomy was done followed by ensuring
were closed by 3/0 Vicryl. Sterile bandage was hemostasis. Abdomen close in layer by layer, sterile
given. bandage was given.
 OPERATION NOTE OPERATION NOTE
Laparoscopic cholecystectomy Open cholecystectomy
Name of the patient: Name of the patient:
Bed/ Cabin No.: Registration No.: Bed/ Cabin No.: Registration No.:
Date: Time: Date: Time:
Diagnosis: Diagnosis:
Indication: Indication:
Surgeon: Surgeon:
Aneasthesist: Aneasthesist:
Assistant: Assistant:
Anaesthesia: G/A Anaesthesia: G/A
Surgery Done: Laparoscopic cholecystectomy. Surgery Done: Open cholecystectomy.
Procedure & Findings: Procedure & Findings:
With all the aseptic precaution under general With all the aseptic precaution under general
anaesthesia in supine position, povidone painting anaesthesia in supine position, povidone painting
was done followed by proper draping. Then was done followed by proper draping. Then right
umbilical port was made. Pneumoperitoneum was subcostal incision was given. After entering into
created. Then other 3 ports were made. Identification abdominal cavity, Identification of cystic duct &
and isolation of cystic duct & cystic artery followed cystic artery was done followed by excision &
by excision was done. Gall bladder was separated ligation. Separation of Gall bladder fossa was done.
from its bed by hook diathermy. Gall bladder was Multiple stones were found in Gall bladder. Proper
removed. Proper hemostasis achieved. Ports were hemostasis was achieved. Abdomen was closed in
closed by 2/0 Vicryl. Sterile bandage was given. layers. Sterile bandage was given.
 OPERATION NOTE OPERATION NOTE
Hernioplasty LIS (Lateral internal sphincterotomy)
Name of the patient: Name of the patient:
Bed/ Cabin No.: Registration No.: Bed/ Cabin No.: Registration No.:
Date: Time: Date: Time:
Diagnosis: Diagnosis:
Indication: Indication:
Surgeon: Surgeon:
Aneasthesist: Aneasthesist:
Assistant: Assistant:
Anaesthesia: SAB Anaesthesia: SAB
Surgery Done: Hernioplasty. Surgery Done: Lateral internal sphincterotomy.
Procedure & Findings: Procedure & Findings:
With all the aseptic precaution under SAB in supine With all the aseptic precaution under SAB in
position, povidone painting was done followed by lithotomy position, povidone painting was done
proper draping. Abdomen was opened by an inguinal followed by proper draping. Identification of fissure,
incision made. After entering into abdominal cavity, fistula was done. Followed by a guideware was
Identification of the hernial sac & incision of content given through the fistula. LIS and fistulectomy done.
was done. 15/15 composite proline mesh was given Bleeding was average. After proper hemostasis
in situ below the hernial opening. After proper sterile pad bandage was given.
hemostasis incision was closed by 3/0 Vicryl.
Abdomen was closed in layers. Sterile bandage was
given.
 OPERATION NOTE
LONGO – Stapled Hemorrhoidopexy
Name of the patient:
Bed/ Cabin No.: Registration No.:
Date: Time:
Diagnosis:
Indication:
Surgeon:
Aneasthesist:
Assistant:
Anaesthesia: SAB
Surgery Done: LONGO–Stapled
Hemorrhoidopexy

Procedure & Findings:

With all the aseptic precaution under SAB in
lithotomy position, povidone painting was done
followed by proper draping. Identification of
hemorrhoids were done. Followed by stapled
hemorrhoidopexy was done with LONGO. A sterile
pack was ket in situ. Patient is being catheterized.