Medical Specialty:
Urology
Sample Name: Cystourethroscopy & Urethral Dilation
Description: Cystourethroscopy, urethral dilation, and bladder biopsy and fulguration. Urinary hesitancy and weak stream, urethral narrowing, mild posterior wall erythema.
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Urinary hesitancy and weak stream.
POSTOPERATIVE DIAGNOSES:
1. Urinary hesitancy and weak stream.
2. Urethral narrowing.
3. Mild posterior wall erythema.
PROCEDURE PERFORMED:
1. Cystourethroscopy.
2. Urethral dilation.
ANESTHESIA: General.
SPECIMEN: Urine culture sensitivity and cytology and bladder biopsy x1.
DISPOSITION: To PACU in stable condition.
INDICATIONS AND FINDINGS: This is a 76-year-old female with history of weak stream and history of intermittent catheterization secondary to hypotonic bladder in the past, last cystoscopy approximately two years ago.
DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient was moved to the operating room, general anesthesia was induced by the Department of Anesthesia. The patient was prepped and draped in normal sterile fashion and urethral sounds used to dilate the urethra to accommodate #23 French cystoscope. Cystoscopy was performed in its entirety with the above findings. The small area of erythema on the posterior wall was biopsied using a flexible biopsy forceps and Bovie cautery was used to cauterize and fulgurate this area. The bladder was drained, cystoscope was removed, scope was reinserted and bladder was again reexamined. No evidence of active bleeding noted. The bladder was drained, cystoscope was removed, and the patient was cleaned and sent to recovery room in stable condition to followup with Dr. X in two weeks. She is given prescription for Levaquin and Pyridium and given discharge instructions.
Keywords: urology, bladder biopsy, fulguration, urethral dilation, weak stream, bladder, cystoscopy, cystoscope, cystourethroscopy, biopsy, urethral,