Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Urology
Sample Name: Cystourethroscopy & TURP

Description: Benign prostatic hypertrophy and urinary retention. Cystourethroscopy and transurethral resection of prostate (TURP).
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSES:
1. Benign prostatic hypertrophy.
2. Urinary retention.

POSTOPERATIVE DIAGNOSES:
1. Benign prostatic hypertrophy.
2. Urinary retention.

PROCEDURE PERFORMED:
1. Cystourethroscopy.
2. Transurethral resection of prostate (TURP).

ANESTHESIA: Spinal.

DRAIN: A #24 French three-way Foley catheter.

SPECIMENS: Prostatic resection chips.

ESTIMATED BLOOD LOSS: 150 cc.

DISPOSITION: The patient was transferred to the PACU in stable condition.

INDICATIONS AND FINDINGS: This is an 84-year-old male with history of BPH and subsequent urinary retention with failure of trial of void, scheduled for elective TURP procedure.

FINDINGS: At the time of surgery, cystourethroscopy revealed trilobar enlargement of the prostate with prostatic varices of the median lobe. Cystoscopy showed a few cellules of the bladder with no obvious bladder tumors noted.

DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient was moved to operating room and spinal anesthesia was induced by the Department of Anesthesia. The patient was prepped and draped in the normal sterile fashion and a #21 French cystoscope inserted into urethra and into the bladder. Cystoscopy performed with the above findings. Cystoscope was removed. A #27 French resectoscope with a #26 cutting loop was inserted into the bladder. Verumontanum was identified as a landmark and systematic transurethral resection of the prostate tissue was undertaken in an circumferential fashion with good resection of tissue completed. ________ irrigator was used to evacuate the bladder of prostatic chips. Resectoscope was then inserted and any residual chips were removed in piecemeal fashion with a resectoscope loop. Any obvious bleeding from the prostatic fossa was controlled with electrocautery. Resectoscope was removed. A #24 French three-way Foley catheter inserted into the urethra and into the bladder. Bladder was irrigated and connected to three-way irrigation. The patient was cleaned and sent to recovery in stable condition to be admitted overnight for continuous bladder irrigation and postop monitoring.

Keywords: urology, urinary retention, cystourethroscopy, transurethral resection of prostate, foley catheter, bph, cystoscopy, bladder, benign prostatic hypertrophy, turp,
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.
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Transcribed Medical Transcription Sample Reports and Examples