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OB GYN Operative Medical Transcription Sample Report

PREOPERATIVE DIAGNOSES:
1. Missed abortion.
2. Rh positive.

POSTOPERATIVE DIAGNOSES:
1. Missed abortion.
2. Rh positive.

OPERATION PERFORMED: Sharp and suction dilatation and curettage.

SURGEON:
Jane Doe, MD

ASSISTANT: None.

ANESTHESIA: Laryngeal mask anesthesia.

ANESTHESIOLOGIST: John Doe, MD

IV FLUIDS: 500 mL of crystalloid.

URINE OUTPUT:
75 mL.

ESTIMATED BLOOD LOSS: 50 mL.


ANTIBIOTICS: Ancef 2 grams.

DESCRIPTION OF OPERATION: After proper and informed consent was obtained, the patient was taken to operating room where she was placed in the supine position and given laryngeal mask anesthesia. Legs were placed in the low lithotomy position and exam under anesthesia revealed her uterus to be mildly enlarged, anteflexed, mobile, with a closed cervical os. She was then prepped and draped in the usual sterile fashion for a vaginal procedure. She received Ancef 2 grams preoperatively.


A red rubber catheter was used to drain her bladder of 75 mL of clear urine. A speculum was placed in the vagina and the cervix was visualized and grasped with ring forceps. Using the cervical dilator, the cervix was gently and gradually dilated in order to accommodate a #7 curved suction uterine curette. The suction curette was introduced through the cervix to the uterus where a suction curettage was performed revealing a small amount of products of conception. After removal of the suction curette, sharp uterine curettage was performed in all quadrants until an adequate uterine cry was obtained. The suction curette was once again reintroduced through the cervix where a suction curettage was performed until no further debris remained.

All instrumentation was then removed from the vagina. The cervix was visualized and hemostasis was noted. The patient was returned from low lithotomy position to supine position, awakened from general endotracheal anesthesia, and taken from the operating room to the recovery room in stable condition, having tolerated the procedure well. The sponge and instrument counts were correct.

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Dysfunctional uterine bleeding and cervical dysplasia, colposcopically proven.

POSTOPERATIVE DIAGNOSIS:  Dysfunctional uterine bleeding and cervical dysplasia, colposcopically proven.

OPERATION PERFORMED:  LEEP and hysteroscopy, D&C.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

COMPLICATIONS:  None.

ESTIMATED BLOOD LOSS:  Minimal.

DESCRIPTION OF OPERATION:  The patient was taken to the OR and satisfactory general anesthesia was obtained.  Draped and prepped in the usual sterile fashion and placed in the dorsal lithotomy position.  The bladder was drained via straight catheter and a bivalve speculum inserted.  The cervix was visualized and grasped across anterior lip with a single tooth tenaculum.  The uterus was sounded to 8 cm at this time.  The cervical os was gently dilated to 5 mm with Hegar dilators and hysteroscope introduced in the patient's uterine cavity.  With approximately 6 mL of warm sterile saline, the uterine cavity was visualized.  There appeared to be no evidence of abnormal pathology, no evidence of endometrial hyperplasia or malignancy.  No evidence of fibroid formation.  There was some sloughing endometrium.  There was perhaps a small 1 to 2 mm polyp anteriorly.

At this time, a thorough curettage was accomplished with smooth and serrated endometrial curettes.  Endometrial curettings were submitted for pathological evaluation on a Telfa gauze.  At this time, instruments were removed from the patient's uterine cavity.  With smoke evacuation in place, a loop electrosurgical excision procedure was accomplished with a 12 x 20 mm loop with excision of the ecto and endocervical tissue.  The LEEP bed was made hemostatic with the Bovie electrocautery device.  Bleeding was minimal.  The specimen was submitted for pathologic evaluation.

At this time, instruments were removed from the patient's vaginal vault.  The patient tolerated the procedure well and was taken to the recovery room in stable condition.  Sponge counts were correct x3.