Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Obstetrics / Gynecology
Sample Name: LEEP

Description: LEEP procedure of endocervical polyp and Electrical excision of pigmented mole of inner right thigh.
(Medical Transcription Sample Report)

DIAGNOSIS:
1. Broad-based endocervical poly.
2. Broad- based pigmented, raised nevus, right thigh.

OPERATION:
1. LEEP procedure of endocervical polyp.
2. Electrical excision of pigmented mole of inner right thigh.

FINDINGS: There was a 1.5 x 1.5 cm broad-based pigmented nevus on the inner thigh that was excised with a wire loop. Also, there was a butt-based, 1-cm long endocervical polyp off the posterior lip of the cervix slightly up in the canal.

PROCEDURE: With the patient in the supine position, general anesthesia was administered. The patient was put in the dorsal lithotomy position and prepped and draped for dilatation and curettage in a routine fashion.

An insulated posterior weighted retractor was put in. Using the LEEP tenaculum, we were able to grasp the anterior lip of the cervix with a large wire loop at 35 cutting, 30 coagulation. The endocervical polyp on the posterior lip of the cervix was excised.

Then changing from a 50 of coagulation and 5 cutting, the base of the polyp was electrocoagulated, which controlled all the bleeding. The wire loop was attached, and the pigmented raised nevus on the inner thigh was excised with the wire loop. Cautery of the base was done, and then it was closed with figure-of-eight 3-0 Vicryl sutures. A band-aid was applied over this.

Rechecking the cervix, no bleeding was noted. The patient was laid flat on the table, awakened, and moved to the recovery room bed and sent to the recovery room in satisfactory condition.

Keywords: obstetrics / gynecology, endocervical polyp, pigmented mole, polyp, leep tenaculum, leep, cervix, endocervical, pigmented,
NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports. These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the preference of the dictating physician. All names and dates have been changed (or removed) to keep confidentiality. Any resemblance of any type of name or date or place or anything else to real world is purely incidental.
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Transcribed Medical Transcription Sample Reports and Examples