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: Cone Biopsy

Description: Cervical cone biopsy, dilatation & curettage
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Cervical carcinoma in situ.

POSTOPERATIVE DIAGNOSIS: Cervical carcinoma in situ.

OPERATION PERFORMED: Cervical cone biopsy, dilatation & curettage.

SPECIMENS: Cone biopsy, endocervical curettings, endometrial curettings.

INDICATIONS FOR PROCEDURE: The patient recently presented with a Pap smear showing probable adenocarcinoma in situ. The patient was advised to have cone biopsy to fully assess endocervical glands.

FINDINGS: During the examination, under anesthesia, the vulva, vagina, and cervix were grossly unremarkable. The uterus was smooth with no palpable cervical nodularity and no adnexal masses were noted.

PROCEDURE: The patient was brought to the Operating Room with an IV in place. Anesthetic was administered and she was placed in the lithotomy position. The patient was prepped and draped after which a weighted speculum was placed in the vagina and a tenaculum was placed on the cervix for traction. Angle stitches of 0 Vicryl sutures were placed at 3 o'clock and 9 o'clock in the lateral vagina fornices. The cervix was stained with Lugol's iodine solution.

After the cervix was stained, a scalpel was used to excise a cone shaped biopsy circumferentially around the cervical os. The specimen was removed intact, after which the uterine cavity was sounded to a depth of 8 cm. A Kevorkian curette was used to obtain endocervical curettings. The cone biopsy site was sutured using a running lock stitch of 0 Vicryl suture. Upon completion of the suture placement, the endocervical canal was sounded to assure patency. A prophylactic application of Monsel's solution completed the procedure.

The patient was awakened from her anesthetic and taken to the post anesthesia care unit in stable condition. Final sponge, needle, and instrument counts were.

Keywords: obstetrics / gynecology, cervical carcinoma in situ, cervical cone biopsy, endometrial curettings, endocervical, endometrial, dilatation & curettage, carcinoma in situ, cone biopsy, dilatation, curettage, carcinoma, vicryl, curettings, vagina, sutures, cervix, cervical, cone, biopsy,
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