Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
|

View this sample in Blog format on MedicalTranscriptionSamples.com

Sample Type / Medical Specialty: Surgery
Sample Name: Suction, Dilation, & Curettage - 1

Description: Suction dilation and curettage for incomplete abortion. On bimanual exam, the patient has approximately 15-week anteverted, mobile uterus with the cervix that is dilated to approximately 2 cm with multiple blood colts in the vagina. There was a large amount of tissue obtained on the procedure.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Incomplete abortion.

POSTOPERATIVE DIAGNOSIS: Incomplete abortion.

PROCEDURE PERFORMED: Suction dilation and curettage.

ANESTHESIA: General and nonendotracheal by Dr. X.

ESTIMATED BLOOD LOSS: Less than 200 cc.

SPECIMENS: Endometrial curettings.

DRAINS: None.

FINDINGS: On bimanual exam, the patient has approximately 15-week anteverted, mobile uterus with the cervix that is dilated to approximately 2 cm with multiple blood colts in the vagina. There was a large amount of tissue obtained on the procedure.

PROCEDURE: The patient was taken to the operating room where a general anesthetic was administered. She was then positioned in the dorsal lithotomy position and prepped and draped in the normal sterile fashion. Once the anesthetic was found to be adequate, a bimanual exam was performed under anesthetic. Next, a weighted speculum was placed in the vagina. The anterior lip of cervix was grasped with the vulsellum tenaculum and due to the patient already being dilated approximately 2 cm, no cervical dilation was needed. A size 12 straight suction curette was used and connected to the suction and was placed in the cervix and a suction curettage was performed. Two passes were made with the suction curettage. Next, a sharp curettage was performed obtaining a small amount of tissue and this was followed by third suction curettage and then a final sharp curettage was performed, which revealed a good uterine cry on all sides of the uterus. After the procedure, the vulsellum tenaculum was removed. The cervix was seemed to be hemostatic. The weighted speculum was removed. The patient was given 0.25 mg of Methergine IM approximately half-way through the procedure. After the procedure, a second bimanual exam was performed and the patient's uterus had significantly decreased in size. It is now approximately eight to ten-week size. The patient was taken from the operating room in stable condition after she was cleaned. She will be discharged on today. She was given Methergine, Motrin, and doxycycline for her postoperative care. She will follow-up in one week in the office.

Keywords: surgery, uterus, anteverted, dorsal lithotomy position, weighted speculum, mobile uterus, vulsellum tenaculum, bimanual exam, vagina, tenaculum, dilation, bimanual, cervix, suction, 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.
Home | MedicalTranscriptionSamples | MT911 | MTDictionary | MTSetup | MTHelpLine
Sitemap | Tell a Friend | Contact Us | Disclaimer

Transcribed Medical Transcription Sample Reports and Examples