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Urology Medical Transcription Procedure Sample Reports

DATE OF PROCEDURE: MM/DD/YYYY

PREOPERATIVE DIAGNOSES: Right hydronephrosis, right renal colic, hematuria, recurrent interstitial cystitis, and irritative/obstructive urinary bladder symptoms.

POSTOPERATIVE DIAGNOSES: Right hydronephrosis, right renal colic, hematuria, recurrent interstitial cystitis, irritative/obstructive urinary bladder symptoms, hemorrhagic cystitis, right distal ureteritis, no evidence of gross right ureteropelvic junction obstruction, right pyelocaliectasis, female urethral syndrome with subacute interstitial cystitis, mild leukoplakia, and severe trigonitis.

PROCEDURES PERFORMED: Urethral calibration, dilatation, right diagnostic ureteroscopy with transureteroscopic fulguration of all right distal ureteric bleeding points, retrograde pyelogram, hydrodistention, hydrodilation of urinary bladder, transurethral fulguration of all bleeders, especially trigone region.

SURGEON: John Doe, MD

ANESTHESIA: General anesthesia.

COMPLICATIONS: None.

INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old female referred because of right hydronephrosis, right renal colic with hematuria plus irritative/obstructive bladder symptoms. Evaluation showed the above findings. Options were offered to the patient, of which she agrees to undergo the above-mentioned procedure. General information, alternatives and risks were explained to the patient. The patient understands and agrees to undergo the above-mentioned procedure.

PROCEDURE IN DETAIL: The patient was brought to the cystoscopy suite. General anesthesia was then given. The patient was then placed in the dorsal lithotomy position. The patient was then scrubbed, prepped and draped in the usual sterile manner. General evaluation showed grade 1 cystocele with urethral meatal stenosis, calibrated at French #10 and #12. Urethral meatal opening was progressively dilated to French #20, #22 and #24 using the female urethral sounds. Then passed a #22 French cystourethroscope instrument into the female urethra, into the bladder, showing acute female urethritis, mild leukoplakia, severe trigonitis. Classic picture of interstitial cystitis changes were observed, including ulceration, glomerulation, submucosal hemorrhages and petechia. The right ureteric orifice was found to be gaping and hemorrhagic.

At this point in time, ureteroscopic evaluation was carried out showing evidence of subacute right distal ureteritis with bleeding hemorrhagic lesions. There was no gross obstructive uropathy, no gross evidence of ureteric stricture or evidence of gross obstructive stricture formation involving the right ureteropelvic junction. There was mild pyelocaliectasis as confirmed by a right retrograde ureteropyelogram study that was performed. There were no complications during the ureteroscopic evaluation such as ureteric rupture, ureteric bleeding or evidence of urinary extravasation. From the retrograde study, we diverted our attention to the interstitial cystitis. Hydrodistention, hydrodilation of the urinary bladder was then carried out to a maximum bladder capacity of approximately 425 mL x2 cycles. During this maximum bladder filling, all bleeding points, especially in the trigone region, were electrocoagulated and fulgurated. Satisfactory hemostasis was then initiated and completed.

The procedure was terminated, bladder decompressed and the scope was then withdrawn. The patient was then transferred to the recovery room in satisfactory condition. Postoperative orders were given.

DATE OF PROCEDURE:  MM/DD/YYYY

PROCEDURE PERFORMED:  Right extracorporeal shock-wave lithotripsy.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

CHIEF COMPLAINT:  Right renal stones.

INDICATION FOR PROCEDURE:  This patient is a (XX)-year-old woman who presented with a 1 cm obstructing right ureteral stone with urosepsis. The stone was pushed back into the kidney and the kidney drained with a stent. She went on to obtain successful antibiotic therapy and now returns for definitive stone treatment.

OPERATIVE FINDINGS:  Two stones, each one approximately 1 cm in the right kidney, both of which were fragmented adequately with shock-wave lithotripsy.

PROCEDURE FINDINGS AND DETAILS OF PROCEDURE:  After the patient obtained adequate general anesthesia, she was placed in supine position on the lithotripsy table. Using fluoroscopic guidance, the stone in the renal pelvis, which had been the obstructing stone, was placed at the focal point of the shock waves. A total of 1500 shocks were delivered with excellent fragmentation.

The patient subsequently manipulated so that the lower pole of stone, also approximately 1 cm, was identified and placed at the focal point of the shock waves. Another 1500 shocks were delivered to this, once again with excellent fragmentation. The patient tolerated the procedure well and was transferred to the recovery room in satisfactory condition.