Medical Specialty:
Obstetrics / Gynecology
Sample Name: D&C & Laparoscopy
Description: Enlarged fibroid uterus, infertility, pelvic pain, and probable bilateral tubal occlusion. Dilatation and curettage and laparoscopy and injection of indigo carmine dye.
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSES:
1. Hypermenorrhea.
2. Pelvic pain.
3. Infertility.
POSTOPERATIVE DIAGNOSES:
1. Enlarged fibroid uterus.
2. Infertility.
3. Pelvic pain.
4. Probable bilateral tubal occlusion.
PROCEDURE PERFORMED:
1. Dilatation and curettage.
2. Laparoscopy.
3. Injection of indigo carmine dye.
GROSS FINDINGS: The uterus was anteverted, firm, enlarged, irregular, and mobile. The cervix is nulliparous without lesions. Adnexal examination was negative for masses.
PROCEDURE: The patient was placed in the lithotomy position, properly prepared and draped in sterile manner. After bimanual examination, the cervix was exposed with a weighted vaginal speculum and the anterior lip of the cervix was grasped with vulsellum tenaculum. Uterus sounded to a depth of 10.5 cm. Endocervical canal was progressively dilated with Hanks dilators to #20-French. A medium-sized sharp curet was used to obtain a moderated amount of tissue upon curettage, which was taken from all uterine quadrants and sent to the pathologist for analysis. A ________ syringe was then introduced into the uterine cavity to a depth of 9 cm and the balloon insufflated with 10 cc of air. A 20 cc syringe filled with dilute indigo carmine dye was attached to the end of the ________ syringe to use to inject at the time of laparoscopy.
Keywords: obstetrics / gynecology, dilatation and curettage, laparoscopy, pelvic pain, infertility, enlarged fibroid uterus, tubal occlusion, indigo carmine dye, fibroid uterus, uterus infertility, peritoneal cavity, fallopian tubes, indigo carmine, endocervical, uterine, pelvic, curettage, uterus,