Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Urology
Sample Name: TURBT - 1

Description: Transurethral resection of the bladder tumor (TURBT), large.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Bladder cancer.

POSTOPERATIVE DIAGNOSIS: Bladder cancer.

OPERATION: Transurethral resection of the bladder tumor (TURBT), large.

ANESTHESIA: General endotracheal.

ESTIMATED BLOOD LOSS: Minimal.

FLUIDS: Crystalloid.

BRIEF HISTORY: The patient is an 82-year-old male who presented to the hospital with renal insufficiency, syncopal episodes. The patient was stabilized from cardiac standpoint on a renal ultrasound. The patient was found to have a bladder mass. The patient does have a history of bladder cancer. Options were watchful waiting, resection of the bladder tumor were discussed. Risk of anesthesia, bleeding, infection, pain, MI, DVT, PE were discussed. The patient understood all the risks, benefits, and options and wanted to proceed with the procedure.

DETAILS OF THE OR: The patient was brought to the OR, anesthesia was applied. The patient was placed in dorsal lithotomy position. The patient was prepped and draped in the usual sterile fashion. A 23-French scope was inserted inside the urethra into the bladder. The entire bladder was visualized, which appeared to have a large tumor, lateral to the right ureteral opening.

There was a significant papillary superficial fluffiness around the left ________. There was a periureteral diverticulum, lateral to the left ureteral opening. There were moderate trabeculations throughout the bladder. There were no stones. Using a French cone tip catheter, bilateral pyelograms were obtained, which appeared normal. Subsequently, using 24-French cutting loop resectoscope a resection of the bladder tumor was performed all the way up to the base. Deep biopsies were sent separately. Coagulation was performed around the periphery and at the base of the tumor. All the tumors were removed and sent for path analysis. There was an excellent hemostasis. The rest of the bladder appeared normal. There was no further evidence of tumor. At the end of the procedure, a 22 three-way catheter was placed, and the patient was brought to the recovery in a stable condition.

Keywords: urology, transurethral resection of the bladder tumor, transurethral resection, bladder cancer, bladder tumor, bladder, turbt, insufficiency, tumor,
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