Obstetrics / Gynecology
Sample Name: Dilation & Evacuation
Description: Dilation and evacuation. 12 week incomplete miscarriage. The patient unlike her visit in the ER approximately 4 hours before had some tissue in the vagina protruding from the os, this was teased out and then a D&E was performed yielding significant amount of central tissue.
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: 12 week incomplete miscarriage.
POSTOPERATIVE DIAGNOSIS: 12 week incomplete miscarriage.
OPERATION PERFORMED: Dilation and evacuation.
OPERATIVE FINDINGS: The patient unlike her visit in the ER approximately 4 hours before had some tissue in the vagina protruding from the os, this was teased out and then a D&E was performed yielding significant amount of central tissue. The fetus of 12 week had been delivered previously by Dr. X in the ER.
SPONGE AND NEEDLE COUNT: Correct.
DESCRIPTION OF OPERATION: The patient was taken to the operating room placed in the operating table in supine position. After adequate anesthesia, the patient was placed in dorsal lithotomy position. The vagina was prepped. The patient was then draped. A speculum was placed in the vagina. Previously mentioned products of conception were teased out with a ring forceps. The anterior lip of the cervix was then grasped with a ring forceps as well and with a 10-mm suction curette multiple curettages were performed removing fairly large amount of tissue for a 12-week pregnancy. A sharp curettage then was performed and followed by two repeat suction curettages. The procedure was then terminated and the equipment removed from the vagina, as well as the speculum. The patient tolerated the procedure well. Blood type is Rh negative. We will see the patient back in my office in 2 weeks.
Keywords: obstetrics / gynecology, incomplete miscarriage, dilation, evacuation, vagina protruding, protruding, speculum, miscarriage, forceps, curettages, vagina,