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: Dilatation & Curettage - D&C

Description: Fractional dilatation and curettage
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Postmenopausal bleeding.

POSTOPERATIVE DIAGNOSIS: Same.

OPERATION PERFORMED: Fractional dilatation and curettage.

SPECIMENS: Endocervical curettings, endometrial curettings.

INDICATIONS FOR PROCEDURE: The patient recently presented with postmenopausal bleeding. An office endometrial biopsy was unable to be performed secondary to a stenotic internal cervical os.

FINDINGS: Examination under anesthesia revealed a retroverted, retroflexed uterus with fundal diameter of 6.5 cm. The uterine cavity was smooth upon curettage. Curettings were fairly copious. Sounding depth was 8 cm.

PROCEDURE: The patient was brought to the Operating Room with an IV in place. The patient was given a general anesthetic and was placed in the lithotomy position. Examination under anesthesia was completed with findings as noted. She was prepped and draped and a speculum was placed into the vagina.

Tenaculum was placed on the cervix. The endocervical canal was curetted using a Kevorkian curette, and the sound was used to measure the overall depth of the uterus. The endocervical canal was dilated without difficulty to a size 16 French dilator. A small, sharp curette was passed into the uterine cavity and curettings were obtained.

After completion of the curettage, polyp forceps were passed into the uterine cavity. No additional tissue was obtained. Upon completion of the dilatation and curettage, minimum blood loss was noted.

The patient was awakened from her anesthetic, and taken to the post anesthesia care unit in stable condition.

Keywords: obstetrics / gynecology, postmenopausal bleeding, endometrial, fractional dilatation, fractional dilatation and curettage, endocervical, dilatation and curettage, endocervical canal, uterine cavity, curetted, dilatation, curettings, curettage,
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