Sample Name: Condyloma Cauterization
Description: Cauterization of peri and intra-anal condylomas. Extensive perianal and intra-anal condyloma which are likely represent condyloma acuminata.
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Extensive perianal and intra-anal condyloma.
POSTOPERATIVE DIAGNOSIS: Extensive perianal and intra-anal condyloma.
PROCEDURE PERFORMED: Cauterization of peri and intra-anal condylomas.
ANESTHESIA: IV sedation and local.
SPECIMEN: Multiple condylomas were sent to pathology.
BRIEF HISTORY: This is a 22-year-old female, who presented to the office complaining of condylomas she had noted in her anal region. She has noticed approximately three to four weeks ago. She denies any pain but does state that there is some itching. No other symptoms associated.
GROSS FINDINGS: We found multiple extensive perianal and intra-anal condylomas, which are likely represent condyloma acuminata.
PROCEDURE: After risks, benefits and complications were explained to the patient and a verbal consent was obtained, the patient was taken to the operating room. After the area was prepped and draped, a local anesthesia was achieved with Marcaine. Bovie electrocautery was then used to remove the condylomas taking care to achieve meticulous hemostasis throughout the course of the procedure. The condylomas were removed 350 degrees from the perianal and intra-anal regions. After all visible condylomas were removed, the area was again washed with acetic acid solution. Any residual condylomas were then cauterized at this time. The area was then examined again for any residual bleeding and there was none.
DISPOSITION: The patient was taken to Recovery in stable condition. She will be sent home with prescriptions for a topical lidocaine and Vicodin. She will be instructed to do sitz bath b.i.d., and post-bowel movement. She will follow up in the office next week.
Keywords: dermatology, intra-anal, perianal, acuminata, cauterization, condyloma, anal,