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Ob-Gyn Medical Transcription Operative Samples

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Menorrhagia.

POSTOPERATIVE DIAGNOSIS:  Menorrhagia with possible uterine fibroid.

OPERATION:  Hysteroscopy with D and C and endometrial ablation by the NovaSure technique.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD 

ANESTHESIA:  General.

ANESTHESIOLOGIST:  Bradford Doe, MD 

OPERATIVE FINDINGS:  Bulky uterus with suggestion of left anterior uterine wall fibroid, uterine descensus with cystocele and rectocele.

DESCRIPTION OF OPERATION:  After appropriate consent, the patient was taken to the operating room and administered adequate general anesthesia. She was placed in the lithotomy position and prepped and draped. The bladder was emptied. Examination under anesthesia revealed a bulky uterus with descensus with coexisting cystocele and rectocele. There was a suggestion of right anterior cornual uterine fibroid.

A weighted speculum was inserted into the posterior vaginal fornix. The anterior cervical lip was held down with a toothed tenaculum. The uterus and the cervix were sounded and measured 11 cm. Hysteroscopy was carried out showing normal endocervical and endometrial cavity. Endocervical and endometrial curettage was carried out yielding profuse curettings which were collected and sent for pathology examination.

A NovaSure endometrial ablation procedure was then performed. The uterine cavity length was registered on the instrument panel. The array was deployed, introduced into the uterus, and the uterine cavity width was measured and entered on the instrument panel. The cavity assessment was successfully completed followed by initiation of the ablation cycle which was completed without difficulty.

All the vaginal instruments were removed. Repeat hysteroscopy showed adequate ablation of the endometrium. All the vaginal instruments were removed. The patient was returned to supine position, awake, and left the operating room in stable condition. There were no complications.

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DATE OF OPERATION: XX/XX/XXXX

PREOPERATIVE DIAGNOSIS: Cervical dysplasia.

POSTOPERATIVE DIAGNOSIS: Cervical dysplasia.

OPERATION PERFORMED: Cold-knife conization and endocervical curetting.

SURGEON:  John Doe, MD

ANESTHESIA: Laryngeal mask airway.

COMPLICATIONS: None.

ESTIMATED BLOOD LOSS: 20 mL.

SPECIMENS: Cold-knife cone specimen and endocervical curettings.

INDICATION: This is a patient with a history of CIN 1 to CIN 3 diagnosed by colposcopy and biopsy. The patient was counseled regarding options for excisional therapy. The patient understood risks, benefits and alternatives to the procedure, and informed consent was signed for cold-knife conization. All questions were answered prior to the procedure.

DESCRIPTION OF OPERATION: The patient was taken to the operating room, where LMA anesthesia was obtained without difficulty. The patient was prepped and draped in the normal sterile fashion in the dorsal lithotomy position using candy cane stirrups. Attention was then turned to the patient's vagina where the weighted speculum was placed into the posterior fornix and a curved Deaver was placed into the anterior fornix. Two sutures of 0 Vicryl were used to ligate the cervical branches of the cervical artery at the 3 and 9 o'clock positions in a figure-of-eight suture. Then, the cervix was injected
with 10 in 200 of Pitressin. Lugol solution was applied to the cervix to see any abnormalities. Cold-knife cone specimen was then obtained. This was handed off for pathologic review. Stitch was placed at the 12 o'clock position. Next, endocervical curetting was performed of the canal. This was handed off also for pathologic review. The base of the cervical cone specimen was then cauterized using Bovie cautery. The margins of the cone specimen were also cauterized in a similar manner. The cone site was noted to be hemostatic. Avitene was then placed into the cervical cone site, the sutures were cut and all the instruments removed from the patient's vagina. All sponge, lap and needle counts were correct x2. The patient tolerated the procedure well, was awakened and transferred to the recovery room.

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