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5013 Samples in 40 Types as on 07/07/2023

Medical Specialty:
Obstetrics / Gynecology

Sample Name: Total Abdominal Hysterectomy - Followup


Description: Postoperative day #1, total abdominal hysterectomy. Normal postoperative course.
(Medical Transcription Sample Report)

POSTOPERATIVE DAY #1, TOTAL ABDOMINAL HYSTERECTOMY

SUBJECTIVE: The patient is alert and oriented x3 and sitting up in bed. The patient has been ambulating without difficulty. The patient is still NPO. The patient denies any new symptomatology from 6/10/2009. The patient has complaints of incisional tenderness. The patient was given a full explanation about her clinical condition and all her questions were answered.

OBJECTIVE:
VITAL SIGNS: Afebrile now. Other vital signs are stable.
GU: Urinating through Foley catheter.
ABDOMEN: Soft, negative rebound.
EXTREMITIES: Without Homans, nontender.
BACK: Without CVA tenderness.
GENITALIA: Vagina, slight spotting. Wound dry and intact.

ASSESSMENT: Normal postoperative course.

PLAN:
1. Follow clinically.
2. Continue present therapy.
3. Ambulate with nursing assistance only.



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Abdominosacrocolpopexy Bilateral Mammogram Bilateral Tubal Occlusion - Laparoscopic Biophysical Profile Biophysical Profile - 1 Breast Calcifications - Preop Consult Breast Mass Excision Breast Mass Excision - 1 Breast Mass Excision - 2 Breast Radiation Therapy Followup Breast Ultrasound & Biopsy BTL & Salpingectomy Cesarean Section Cesarean Section & BTL Cholestasis Of Pregnancy Colpocleisis Complete Physical - Female Cone Biopsy Consult/ER Report - OB/GYN CT Abdomen & Pelvis - OB-GYN Culdoplasty & Vaginal Hysterectomy D&C - Discharge Summary D&C & Hysteroscopy D&C & Hysteroscopy - 1 D&C & Hysteroscopy Followup D&C & Laparoscopy D&C & Laparoscopy - 1 D&C & Laparoscopy - 2 D&C & Tubal Pregnancy Removal D&C, Laparoscopy, & Salpingectomy Delivery Note Delivery Note - 1 Delivery Note - 10 Delivery Note - 2 Delivery Note - 3 Delivery Note - 4 Delivery Note - 5 Delivery Note - 6 Delivery Note - 7 Delivery Note - 8 Delivery Note - 9 Diagnostic Laparoscopy Diagnostic Laparoscopy - 1 Diagnostic Mammogram Dilatation & Curettage - D&C Dilation & Evacuation Ectopic Pregnancy - Discharge Summary Emergency C-section. Endometrial Cancer Followup Exploratory Laparotomy - 2 External Cephalic Version Fetal Anatomical Survey First Pap smear. Full-Field Digital Mammogram (FFDM) - 1 Full-Field Digital Mammogram (FFDM) - 2 Gardnerella Bacterial Vaginosis Hemivulvectomy Hysterectomy - Discharge Summary Hysterectomy - Discharge Summary - 1 Hysterectomy - Discharge Summary - 2 Hysterectomy - Laparoscopic Supracervical Hysterectomy & Salpingoophorectomy Hysterectomy (TAH - BSO) Hysterectomy, BSO, & Appendectomy. Hysteroscopy & Endometrial Ablation Hysteroscopy & Laproscopy with Salpingooophorectomy Induction of Vaginal Delivery Intrauterine Clots Removal Intrauterine Pregnancy - Discharge Summary Laparoscopic Ablation of Eendometrial Implants Laparoscopic Hysterectomy Laparoscopic Supracervical Hysterectomy. Laparoscopy Laparoscopy - 1 Laparoscopy - 2 Laparoscopy - 3 Laparoscopy - 4 Laparoscopy - Drainage of Cyst Laparoscopy & Salpingo-oophorectomy Laparotomy & Myomectomy Laparotomy & Salpingectomy Laser of Vulva LEEP Left Lower Quadrant Pain - ER Visit Low -Segment C-Section Low-Transverse C-Section Low-Transverse C-Section - 1 Low-Transverse C-Section - 10 Low-Transverse C-Section - 2 Low-Transverse C-Section - 3 Low-Transverse C-Section - 4 Low-Transverse C-Section - 5 Low-Transverse C-Section - 6 Low-Transverse C-Section - 7 Low-Transverse C-Section - 8 Low-Transverse C-Section - 9 Low-Transverse C-Section & BTL Low-Transverse C-Section & BTL - 1 Lysis of Pelvic Adhesions Metastatic Ovarian Cancer - Consult MRI Breast - 1 Needle Localized Excision - Breast Neoplasm OB/GYN - H&P OB/GYN Consultation - 1 OB/GYN Consultation - 2 OB/GYN Consultation - 3 OB/GYN Consultation - 4 Pathology - Ovarian Cyst Pelvic Laparotomy Physical Exam and Pap - 1 Physical Exam and Pap -2 Preeclampsia Pre-Eclampsia & Eclampsia Radical Hysterectomy Radical Mastectomy Radical Mastectomy - 1 Radical Vulvectomy Repeat C-section Salpingectomy & Cervical Dilatation Salpingooophorectomy - Laparoscopic Spontaneous Vaginal Delivery Spontaneous Vaginal Delivery - 1 Suction, Dilation, & Curettage Suction, Dilation, & Curettage - 1 TAH - Discharge Summary TAH & BSO TAH & Salpingooophorectomy TAH & Salpingo-oophorectomy TAH & Salpingo-oophorectomy - 1 TAH & Salpingo-oophorectomy & Lysis of Adhesions Three-Week Postpartum Checkup Total Abdominal Hysterectomy Total Abdominal Hysterectomy - 1 Total Abdominal Hysterectomy - 2 Total Abdominal Hysterectomy - 3 Total Abdominal Hysterectomy - Followup True Cut Needle Biopsy - Breast Tubal Fulguration - Laparoscopic Tubal Ligation Tubal Ligation - Laparoscopic Tubal Ligation - Postpartum Tubal Sterilization & Coagulation Ultrasound - Pelvis Ultrasound - Transvaginal Ultrasound OB Ultrasound OB - 1 Ultrasound OB - 2 Ultrasound OB - 3 Ultrasound OB - 4 Ultrasound OB - 5 Ultrasound OB - 6 Ultrasound OB - 7 Ultrasound OB - 8 Uterine Papillary Serous Carcinoma Uterine Suction Curettage Vacuum D&C Vaginal Delivery - Vacuum-Assisted Vaginal Hysterectomy Vaginal Hysterectomy - Laparoscopic-Assisted Well-woman checkup
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Keywords: obstetrics / gynecology, postoperative course, total abdominal hysterectomy, postoperative,