Medical Specialty:
Obstetrics / Gynecology
Sample Name: D&C & Hysteroscopy - 1
Description: Dilation and curettage (D&C) and hysteroscopy. A female presents 7 months status post spontaneous vaginal delivery, has had abnormal uterine bleeding since her delivery with an ultrasound showing a 6 cm x 6 cm fundal mass suspicious either for retained products or endometrial polyp.
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSES:
1. Abnormal uterine bleeding.
2. Status post spontaneous vaginal delivery.
POSTOPERATIVE DIAGNOSES:
1. Abnormal uterine bleeding.
2. Status post spontaneous vaginal delivery.
PROCEDURE PERFORMED:
1. Dilation and curettage (D&C).
ANESTHESIA: IV sedation with paracervical block.
ESTIMATED BLOOD LOSS: Less than 10 cc.
INDICATIONS: This is a 17-year-old African-American female that presents 7 months status post spontaneous vaginal delivery without complications at that time. The patient has had abnormal uterine bleeding since her delivery with an ultrasound showing a 6 cm x 6 cm fundal mass suspicious either for retained products or endometrial polyp.
PROCEDURE: The patient was consented and seen in the preoperative suite. She was taken to the operative suite, placed in a dorsal lithotomy position, and placed under IV sedation. She was prepped and draped in the normal sterile fashion. Her bladder was drained with the red Robinson catheter which produced approximately 100 cc of clear yellow urine. A bimanual exam was done, was performed by Dr. X and Dr. Z. The uterus was found to be anteverted, mobile, fully involuted to a pre-pregnancy stage. The cervix and vagina were grossly normal with no obvious masses or deformities. A weighted speculum was placed in the posterior aspect of the vagina and the anterior lip of the cervix was grasped with the vulsellum tenaculum.
Keywords: obstetrics / gynecology, dilation and curettage, hysteroscopy, abnormal uterine bleeding, spontaneous vaginal delivery, endometrial curettings, vaginal delivery, uterine bleeding, endometrial, d&c, cervix, vaginal, uterine, delivery,