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OB/GYN Medical Transcription Operative Examples

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1. Chronic menorrhagia.
2. Accepted sterilization.
3. Small uterine fibroids.
4. Endocervical polyps.

POSTOPERATIVE DIAGNOSES:
1. Chronic menorrhagia.
2. Accepted sterilization.
3. Small uterine fibroids.
4. Endocervical polyps.
5. Large anterior myoma with significant submucous component filling a significant portion of uterine cavity.

OPERATIONS PERFORMED:
1. Hysteroscopy.
2. Fractional dilatation and curettage and removal of endocervical polyps.
3. Endometrial ablation utilizing the NovaSure System.

SURGEON: John Doe, MD

ASSISTANT:
Jane Doe, MD

ANESTHESIA: General per LMA.

ANESTHESIOLOGIST: Mark Doe, MD

COMPLICATIONS: None.

BLOOD LOSS: 30 mL.

DRAINS:
Bladder straight catheterized intraoperatively.

SPECIMENS TO PATHOLOGY: Endocervical curettings with polyps, endometrial curetting.

DESCRIPTION OF PROCEDURE: The patient was brought to the operating suite in stable condition. Informed consent had been obtained. Risks have been outlined including pain, infection, hemorrhage, laceration of the cervix, perforation of the uterine wall, as well as the fact that ablation procedures are not always 100% effective. The patient had been made aware that fibroids do decrease the probability of success as well. The patient was placed under general anesthesia with LMA and then she was positioned in the lithotomy position. She was prepped and draped in the standard fashion. The bladder was drained of urine with a straight catheter. Bimanual pelvic examination was performed.

A weighted speculum was placed and the cervix was visualized. The anterior lip of the cervix was grasped with a tenaculum. Endocervical polyps were removed with polyp forceps. The endocervical canal was then dilated with a #18 Hanks dilator and uterine cavity was sounded to 9 cm. The endocervical canal had been measured at 3.5 cm, thus giving a cavity length of 5.5 cm, which was placed into the calibration portion of the NovaSure generator system. A 5-mm hysteroscope and sleeve were then advanced and hysteroscopic evaluation in the endocervical canal and uterine cavity were performed with the findings as noted above. Representative photographs were obtained. Hysteroscope was removed. 
Curettage of the endocervical canal and then the endometrial cavity was performed. We obviously were not able to remove this large fibroid with any type of curettage procedure. Hysteroscope was re-advanced, which did confirm this.

Attention was then turned to performing the endometrial ablation with the NovaSure system. The introducer was placed in the uterine cavity and the fan electrode was opened. We were able to achieve a width of 3 cm. The endocervical canal was occluded and with carbon dioxide gas. The system was tested for cavity integrity. A therapy ablation cycle was then performed using bipolar electrocautery over 90 seconds. At the end of the procedure, the fan electrode was brought back into the introducer, which was removed. The hysteroscope was advanced. Hysteroscopic evaluation revealed excellent ablation of the surface area of the uterine cavity behind and beneath the anterior myoma as well as the surface of the myoma. There was no significant bleeding coming from the cervical canal and the instruments were removed.

The patient was awakened and returned to the recovery room in stable condition. Instrument and sponge counts were reported as correct. Estimated blood loss was 30 mL. There were no complications.


DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Cervical intraepithelial neoplasia I and II.

POSTOPERATIVE DIAGNOSIS:  Cervical intraepithelial neoplasia I and II.

OPERATION PERFORMED:  LEEP.

SURGEON:  John Doe, MD

ANESTHESIA:  LMA-induced anesthesia.

ESTIMATED BLOOD LOSS:  Minimal.

IV FLUIDS:  600 mL of crystalloid.

URINE OUTPUT:  50 mL.

SPECIMENS:  LEEP biopsy of the cervix.

OPERATIVE FINDINGS:  Acetowhite changes with atypical vessels at 12 o'clock and 6 o' clock positions on colposcopy.

DESCRIPTION OF OPERATION:  The patient was taken to the operating room where laryngeal mask anesthesia was obtained without difficulty.  The patient was placed in the dorsal supine position with legs in candy-cane stirrups.  Under sterile technique, a catheter was used to drain approximately 50 mL of urine from the bladder.  A bivalve speculum was placed in the vagina without difficulty.  Atypical vessels at the 6 o'clock and 12 o'clock positions were noted.   Acetic acid 3% was applied to the cervix.  Acetowhite changes were noted in circumferential manner around the transformation zone.  Then, 0.25% Marcaine was injected at the 2 o'clock, 4 o'clock, 7 o'clock, and 10 o'clock positions.  A total of approximately 3 mL were used.  Following this and after confirming that the grounding pad was applied, electrical loop was used to excise a portion of the cervix.  After the cervical specimen was removed, hemostasis was obtained using the Bovie.  Good hemostasis was noted.  The bivalve speculum was removed from the vagina.  The specimen was sent to the pathology.  The patient tolerated the procedure well.  All sponge and instrument counts were correct.  The patient was taken to the PACU in stable condition.