Medical Specialty:
Obstetrics / Gynecology

Sample Name: D&C & Hysteroscopy

Description: Enlarged fibroid uterus, hypermenorrhea, and secondary anemia. Dilatation and curettage and hysteroscopy.
(Medical Transcription Sample Report)

1. Enlarged fibroid uterus.
2. Hypermenorrhea.

1. Enlarged fibroid uterus.
2. Hypermenorrhea.
3. Secondary anemia.

1. Dilatation and curettage.
2. Hysteroscopy.

GROSS FINDINGS: Uterus was anteverted, greatly enlarged, irregular and firm. The cervix is patulous and nulliparous without lesions. Adnexal examination was negative for masses.

PROCEDURE: The patient was taken to the operating room where she was properly prepped and draped in sterile manner under general anesthesia. After bimanual examination, the cervix was exposed with a weighted vaginal speculum and the anterior lip of the cervix grasped with a vulsellum tenaculum. The uterus was sounded to a depth of 11 cm. The endocervical canal was then progressively dilated with Hanks and Hegar dilators to a #10 Hegar. The ACMI hysteroscope was then introduced into the uterine cavity using sterile saline solution as a distending media and with attached video camera. The endometrial cavity was distended with fluids and the cavity visualized. Multiple irregular areas of fibroid degeneration were noted throughout the cavity. The coronal areas were visualized bilaterally with corresponding tubal ostia. A moderate amount of proliferative appearing endometrium was noted. There were no direct intraluminal lesions seen. The patient tolerated the procedure well. Several pictures were taken of the endometrial cavity and the hysteroscope removed from the cavity.

A large sharp curet was then used to obtain a moderate amount of tissue, which was the sent to pathologist for analysis. The instrument was removed from the vaginal vault. The patient was sent to recovery area in satisfactory postoperative condition.

Keywords: obstetrics / gynecology, dilatation and curettage, hysteroscopy, anemia, enlarged fibroid uterus, endometrial cavity, hypermenorrhea, fibroid, uterus,