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: Colpocleisis

Description: Colpocleisis and rectocele repair.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSES: Vault prolapse and rectocele.

POSTOPERATIVE DIAGNOSES: Vault prolapse and rectocele.

OPERATION: Colpocleisis and rectocele repair.

ANESTHESIA: Spinal.

ESTIMATED BLOOD LOSS: Minimal.

FLUIDS: Crystalloid.

BRIEF HISTORY OF THE PATIENT: This is an 85-year-old female who presented to us with a vaginal mass. On physical exam, the patient was found to have grade 3 rectocele and poor apical support, and history of hysterectomy. The patient had good anterior support at the bladder. Options were discussed such as watchful waiting, pessary, repair with and without mesh, and closing of the vagina (colpocleisis) were discussed. Risk of anesthesia, bleeding, infection, pain, MI, DVT, PE, morbidity, and mortality of the procedure were discussed.

Risk of infection and abscess formation were discussed. The patient understood all the risks and benefits and wanted to proceed with the procedure. Risk of retention and incontinence were discussed. Consent was obtained through the family members.

DETAILS OF THE OR: The patient was brought to the OR. Anesthesia was applied. The patient was placed in dorsal lithotomy position. The patient had a Foley catheter placed. The posterior side of the rectocele was visualized with grade 3 rectocele and poor apical support. A 1% lidocaine with epinephrine was applied for posterior hydrodissection, which was very difficult to do due to the significant scarring of the posterior part. Attempts were made to lift the vaginal mucosa off of the rectum, which was very, very difficult to do at this point due to the patient's overall poor medical condition in terms of poor mobility and significant scarring. Discussion was done with the family in the waiting area regarding simply closing the vagina and doing a colpocleisis since the patient is actually inactive. Family agreed that she is not active and they rather not have any major invasive procedure especially in light of scarring and go ahead and perform the colpocleisis. Oral consent was obtained from the family and her surgery was preceded. The vaginal mucosa was denuded off using electrocautery and Metzenbaum scissors. Using 0 Vicryl, 2 transverse longitudinal stitches were placed to bring the anterior and the posterior part of the vagina together and was started at the apex and was brought all the way out to the introitus. The vaginal mucosa was pretty much completely closed off all the way up to the introitus. Indigo carmine was given. Cystoscopy revealed there was a good efflux of urine from both of the ureteral openings. There was no injury to the bladder or kinking of the ureteral openings. The bladder was normal. Rectal exam was normal at the end of the colpocleisis repair. There was good hemostasis.

At the end of the procedure, Foley was removed and the patient was brought to recovery in a stable condition.

Keywords: obstetrics / gynecology, vault prolapse, rectocele repair, rectocele, vaginal mass, metzenbaum scissors, ureteral openings, vaginal mucosa, colpocleisis, vaginal, infection,
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