Ob-Gyn Medical Transcription Operative Samples


Medical Transcription Ob-Gyn Operative Sample Report # 1:
 
DATE OF OPERATION:
 
PREOPERATIVE DIAGNOSES:
1.  Term pregnancy.
2.  Previous cesarean section x1.
 
POSTOPERATIVE DIAGNOSES:
1.  Term pregnancy.
2.  Previous cesarean section x1.
 
OPERATION PERFORMED:  Primary low transverse cesarean section.
 
SURGEON:  John Doe, MD
 
ASSISTANT:  Robert Doe, PA-C
 
ANESTHESIA:  Epidural.
 
ANESTHESIOLOGIST:  Jane Doe, MD
 
ESTIMATED BLOOD LOSS:  Less than 750 mL.
 
FINDINGS:  Delivered a boy with Apgars 8/9 at term, three-vessel cord with placenta delivered intact.
 
DESCRIPTION OF OPERATION:  After risks of the procedure were explained to the patient, she was taken to the operating room and placed in a dorsal supine position.  She was prepped and draped in the usual sterile fashion with sufficient epidural anesthesia.  The abdomen was opened through the old Pfannenstiel incision, and the bladder blade was inserted.  Richardson was used for superior retraction.  The uterovesical peritoneum was nicked in midline with Metzenbaum scissors and extended in a curvilinear fashion with formation of a bladder flap.  The uterus was then scored in the midline using the surgeon's knife.  Using both the surgeon's index fingers, the incision was extended transversely.  The infant's head was then delivered and bulb suctioned followed by the delivery of torso and lower body.  The cord was doubly clamped and cut as the infant was passed to the pediatrician in attendance.  The infant received bulb suction prior to the delivery of the head.  Three-vessel cord, placenta were then delivered intact and the uterus was wiped clear of blood and clot with wet laparotomy pads.  The uterus was then closed in single layer interlocking suture of #1 chromic.  Both angles were reinforced with figure-of-eight sutures of #1 chromic suture.  Both gutters were wiped clear of blood and clot with wet laparotomy pads.  The pelvis was then irrigated copiously using normal saline.  The Richardson and bladder blade were removed from the abdominal cavity, and the parietal peritoneum and rectus muscle were closed with running suture of #3-0 Vicryl.  The fascia was closed with running locking suture of #0 Vicryl.  The skin was reapproximated using staples, and a pressure dressing was applied at the surgical site.  The patient was finally taken to the recovery room having tolerated the procedure well without complications.
 
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Medical Transcription Ob-Gyn Operative Sample Report # 2:

DATE OF OPERATION:
 
PREOPERATIVE DIAGNOSES:
1.  Term intrauterine pregnancy.
2.  Previous low transverse cesarean section.
3.  Refusal of trial of labor after cesarean section.
 
POSTOPERATIVE DIAGNOSES:
1.  Term intrauterine pregnancy.
2.  Previous low transverse cesarean section.
3.  Refusal of trial of labor after cesarean section.
 
OPERATION PERFORMED:  Repeat low transverse cesarean section with scar revision.
 
SURGEON:  John Doe, MD
 
ASSISTANT:  Joseph Doe, PA-C
 
ANESTHESIA:  Spinal anesthesia.
 
ANESTHESIOLOGIST:  Jane Doe, CRNA
 
FINDINGS:  A viable male infant delivered vertex, given Apgars of 8 and 9 at one and five minutes respectively with a weight of 8 pounds and 7 ounces.

FLUIDS:  1500 mL of crystalloid.
 
ESTIMATED BLOOD LOSS:  500 mL.
 
URINARY OUTPUT:  150 mL.
 
COMPLICATIONS:  None.
 
SURGICAL COUNTS:  Correct x3.
 
DRAINS:  None.
 
SPECIMENS:  None.
 
DISPOSITION:  To the recovery room in stable condition and the infant to the regular nursery.
 
DESCRIPTION OF PROCEDURE:  The patient was taken to the operating room where a spinal anesthetic was placed.  She was then placed in the dorsal supine position with a wedge under the right flank.  She was then prepped and draped in the usual sterile fashion.  Procedure was begun by resecting the previous incision with the first knife.  The incision was then extended to the level of the fascia with the Bovie.  The fascial layer was scored bilaterally in the midline and the fascial incision was then extended in a curvilinear fashion with the Mayo scissors.  The fascial layer was resected from the muscular layer below by both sharp and blunt dissection.  The muscular layer was dissected along the midline by both sharp and blunt dissection.  Peritoneal layer was then entered and extended bluntly.  The bladder blade was advanced.  The uterovesical fold was then entered with the Metzenbaum scissors, and the incision was then carried in a curvilinear fashion.  Bladder flap was developed.  Bladder blade was advanced.  Lower uterine segment was then scored in a curvilinear fashion, subsequently performing a hysterotomy with notation of clear amniotic fluid.
 
The uterine incision was then extended in a curvilinear fashion.  The infant was then grasped at its vertex with subsequent delivery aided with vacuum.  Mouth and nose were vigorously suctioned.  There was a loose nuchal cord noted.  The infant was then delivered in full, noted to be a viable male infant.  The cord was doubly clamped and cut.  The infant was passed to the pediatric nurse in attendance, noted to be a crying viable male infant.  Placenta was then manually removed.  The uterus was then exteriorized and wrapped with a clean wet lap while another was used to the uterine cavity.  Uterus was massaged until firm.  Bladder blade was advanced.  Edges of the hysterotomy were grasped with ring forceps and hysterotomy was then closed in the following fashion.  The closure was performed with #0 chromic with sutures coming from the opposing angles towards the midline interlocking.  The bladder flap was subsequently approximated with #2-0 Vicryl suture with hemostasis being noted and achieved with figure-of-eight #0 chromic suture.  With hemostasis noted, the uterus was returned to the abdomen.  Notation was made of normal maternal anatomy.  Abdominal gutters were cleaned of serosanguineous fluids and clots, and once performed, the abdominal wall was then closed in the following fashion.
 
The peritoneal layer was approximated with #2-0 Vicryl in a running continuous fashion.  The fascial layer was approximated with #0 Vicryl with sutures coming from the opposing angles towards the midline interlocking every third.  Subcutaneous layer was approximated with a #2-0 plain suture in an interrupted fashion, and the skin edges were approximated with wide sterile staples.  This marked the end of the procedure.  The incision was dressed appropriately, and the patient was subsequently taken to the recovery room in stable condition.


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Medical Transcription Ob-Gyn Operative Sample Report # 3:
 
DATE OF OPERATION: 
 
PREOPERATIVE DIAGNOSES:
1.  Pelvic pain.
2.  Uterine fibroid.
 
POSTOPERATIVE DIAGNOSES:
1.  Pelvic pain.
2.  Uterine fibroid.
 
OPERATION PERFORMED:  Total abdominal hysterectomy with right salpingo-oophorectomy.
 
SURGEON:  John Doe, MD
 
ASSISTANT:  Jane Doe, MD
 
ANESTHESIA:  General anesthesia via oral endotracheal tube intubation.
 
ANESTHESIOLOGIST:  Jill Doe, MD
 
NURSE ANESTHETIST:  Joseph Doe, CRNA
 
FINDINGS:  A large pedunculated fibroid measuring approximately 7-8 cm in size and otherwise normal-sized uterus with small uterine fibroids and normal-appearing right ovary.
 
FLUIDS:  1700 mL of crystalloid.
 
URINE OUTPUT:  100 mL.
 
ESTIMATED BLOOD LOSS:  200 mL.
 
COMPLICATIONS:  None.
 
SURGICAL COUNT:  Correct x3.
 
DRAINS:  Foley to straight drain with clear urine.
 
SPECIMENS:  Uterus and right ovary with fallopian tube to pathology.
 
DISPOSITION:  The patient was sent to the recovery room in stable condition.
 
DESCRIPTION OF OPERATION:  The patient was taken to the operating room and was placed in a dorsal supine position.  She was then placed under general anesthesia and intubated.  She was then examined under anesthesia with notation of a 14-16 week sized uterus, relatively elongated, with what appeared to be a large lower uterine segment fibroid as well.  The patient was then prepped and draped in the usual sterile fashion.
 
The procedure was begun by performing a Pfannenstiel incision through the previous scar with the first knife.  The incision was extended to the level of the fascia using Bovie coagulation.  The fascia was scored bilaterally at the midline.  The fascial incision was then extended in a curvilinear fashion using the Mayo scissors.  The fascia was dissected from the muscular area below by both sharp and blunt dissection.  The muscular area was dissected along the midline by both sharp and blunt dissection.  The peritoneum was subsequently entered.  The incision was then extended in a vertical fashion using Metzenbaum scissors.  Immediate notation was made of a large uterine fibroid, and in delivering the fibroid through the abdominal incision, it was noted that the fibroid was primarily in the fundus of the uterus measuring approximately 7-8 cm in size.  Indeed, what was felt to be a low uterine segment fibroid was the uterus itself.  The right ovary was within normal limits.  With these findings noted, the fibroid was subsequently amputated using 2 large Zeppelin clamps, cut and the fundus of the uterus was suture ligated with 0 Vicryl suture.  The specimen was passed to the side to be sent to pathology.
 
A self-retaining Balfour retractor was placed into the abdomen.  The abdominal contents were packed in the upper abdomen using 2 clean wet laps.  Two large Kelly clamps were placed above the cornual portion of the uterus, and the hysterectomy was begun by transecting the round ligaments, which were subsequently suture ligated with 0 Vicryl suture and tag.  Uterovesical peritoneum was subsequently incised with the Metzenbaum scissors, and incision was extended to the sidewall on the right side allowing dissection to the sidewall and subsequent visualization of the uterus.  Once the uterus was felt free, the infundibulopelvic ligaments were then grasped with 2 curved Zeppelin clamps, subsequently cut and the pedicle was initially free tied with 0 Vicryl and subsequently suture ligated with 0 Vicryl suture.  Attention was then turned to the round ligament, which was also secured in the previous fashion.
 
The uterine vessels were subsequently skeletonized, subsequently grasped with curved Heaney clamps, cut and suture ligated with 0 Vicryl suture.  Cardinal ligaments on either side were subsequently grasped, cut and suture ligated with 0 Vicryl suture to the level of the uterosacral ligaments, which were then grasped with curved Zeppelin clamps, cut and suture ligated with 0 Vicryl suture.  These sutures were left long and tagged with hemostats.  Subsequently, 2 large clamps were placed about the upper vaginal cuff.  The specimen was subsequently dissected free with the Jorgenson scissors, and the pedicles were suture ligated with 0 Vicryl suture.  The vaginal cuff was also closed with 0 Vicryl suture in an interrupted fashion.  Subsequently, the pelvis was irrigated until clear.  Points of bleeding were secured either by Bovie coagulation or by suture ligature with a 0 Vicryl suture.  Once hemostasis was achieved, the Balfour retractor was subsequently removed.

Laps were subsequently removed and the abdominal wall was closed in the following fashion.  The peritoneum was approximated with a 2-0 Vicryl in a running continuous fashion.  The fascial layers were approximated with 0 Vicryl with sutures coming from the closing angles interlocking every third towards the midline.  The subcutaneous layer was not approximated.  The skin edges were approximated with wide sterile staples.  The patient tolerated the procedure well.  The uterus, fibroid and right ovary with fallopian tube were sent to pathology together.  The incision was subsequently dressed appropriately, and the patient was then taken to the recovery room in stable condition after extubation.
 
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Medical Transcription Ob-Gyn Operative Sample Report # 4:
 
DATE OF OPERATION: 
 
PREOPERATIVE DIAGNOSES:
1.  Left adnexal cyst, questionable hydrosalpinx versus left ovarian cyst.
2.  Tubal occlusion.
3.  Pelvic adhesions.
 
POSTOPERATIVE DIAGNOSES:
1.  Pelvic adhesions, moderate.
2.  Bilateral hydrosalpinges.
3.  Mild endometriosis with associated atypical pelvic pain.
 
OPERATIONS/PROCEDURES PERFORMED:
1.  Examination under anesthesia.
2.  Chromopertubation.
3.  Operative laparoscopy with CO2 laser.
4.  Adhesiolysis, ovariolysis and bowel adhesiolysis.
5.  Bilateral tuboplasty.
6.  Vaporization of endometriosis implants.
7.  Placement of Interceed.
 
SURGEON:  John Doe, MD
 
ASSISTANT:  Jane Doe, MD
 
ANESTHESIA:  General intubation.
 
ANESTHESIOLOGIST:  Jill Doe, MD
 
ESTIMATED BLOOD LOSS:  Minimal.
 
DRAINS:  None.
 
ANTIBIOTICS:  Ancef 1 gram IV piggyback.
 
COMPLICATIONS:  None.
 
OPERATIVE FINDINGS:  Examination under anesthesia revealed a mid to slightly anterior uterus, which sounded to 7 cm.  There was no adnexal mass appreciated, although there was fullness on the left.  Laparoscopic visualization of the pelvis confirmed that the patient has what appears to be a normal uterus.  The patient's right and left fallopian tubes were involved in adhesion processes, and with chromopertubation, there was bilateral tubal occlusion, although there was minimal, slight leakage from the right distal tube.  The patient's left ovary was encased in adhesions, and initially, I thought there was an ovarian cyst.  Subsequently, it was apparent that this was just a collection of fluid.  There was a peritoneal window or pocket in the cul-de-sac area, and there were areas of endometriosis at the edge of this defect.  Also, there were red raised endometriosis sites seen along both pelvic sidewalls.  There were bowel adhesions to the right upper peritoneal surface.  The appendix was actually normal.  Liver edge was normal.  Gallbladder appeared normal.  Bowel was otherwise normal.  At the conclusion of the procedure, there was bilateral tubal patency with chromopertubation.  There were tubal fimbria tufts, especially seen on the right with a few on the left.  Interceed was used to try to prevent re-adhesions.
 
DESCRIPTION OF OPERATION:  The patient was taken to the operating room where general intubation anesthesia was administered.  The patient was prepared and draped in the dorsal lithotomy position in the usual manner for operative laparoscopy.  A red Robinson catheter was used to drain the patient's urinary bladder, and examination under anesthesia was as described.  Initially, a sterile speculum was used to expose the patient's cervix, which was grasped with a tenaculum.  The uterus was sounded to 7 cm and confirmed to be mid to anterior.  A Cohen-Eder cannula was placed into the cervix, attached to the tenaculum for subsequent uterine manipulation and chromopertubation with methylene blue dye.  The surgeon regloved.  It should be noted throughout the procedure latex-free tubing and equipment were utilized.  Approximately 5 mL of 0.5% Marcaine with epinephrine was injected in the umbilical area.  Subsequently, injections were used for the left lower quadrant as well as the suprapubic incision site subsequently made.
 
A vertical incision was made in the umbilicus.  A step-up Veress needle was inserted into the peritoneal cavity, and approximately 2 liters of carbon dioxide was insufflated into that space until tympany was appreciated over the liver edge.  Following this, the step-up needle with sleeve was reintroduced.  The step-up sleeve was then bluntly expanded using a 10 mm blunt trocar.  Through this port, a diagnostic laparoscope was used to confirm safe placement of the trocar and to visualize the lower pelvis.  With direct visualization, a suprapubic site was chosen and incised.  A Veress needle was inserted under direct visualization and expanded with a 5 mm blunt trocar.  Similar procedure was done in the right lower quadrant area.  Through these various ports, a Nezhat suction-irrigation probe, grasping forceps were utilized.
 
Because of the finding of moderate adhesions and probable endometriosis, the decision was made to prepare the laser.  The coherent Xanar laser was coupled to a waveguide, a power setting of 12 watts superpulse continuous mode was set.  The laser and waveguide was test fired and noted to be functioning well.  During this time, chromopertubation confirmed bilateral tubal occlusion, although there was some leaking from the distal aspect of the right tube.  At this juncture, using the Nezhat as a backstop and using Ringer's lactate solution, the left ovary was addressed and layers of adhesions were incised with great care.  Throughout the procedure, the intraperitoneal pressure was maintained at or less than 14 mmHg.  Following ovariolysis, it was apparent that the left ovary was not cystic but rather this was a loculation of fluid.
 
At this juncture, the left fallopian tube was freed from the pelvic sidewall.  There were multiple adhesions noted.  Once the tube was freed, a cruciate incision was made in the distal aspect of that tube.  There was free flow of methylene blue dye and a few tufts were seen.  The laser was then set at 3 watts continuous mode and the serosal area around this opening was carefully laser vaporized using a modified Bruhat technique.  This led to eversion of the tubal ostium with hopes that this will maintain patency.  The laser was returned to its normal power setting.  Adhesions near the right ovary were laser incised.  Endometriosis sites over both sidewalls were laser vaporized, and a large peritoneal window or pocket was carefully inspected and visible endometriosis sites were vaporized.  Adhesions from bowel to the upper anterior right lower quadrant peritoneal surface were laser incised.  Visualization of the upper abdomen was accomplished.
 
At this juncture, the distal left tube was incised once again using a cruciate incision.  Next, the laser was used at a lower setting to evert the serosal edge.  At this juncture, there was bilateral tubal patency confirmed.  The pelvis was then copiously irrigated with Ringer's lactate solution to remove laser debris, char and methylene blue dye.  Following this, a standard piece of Interceed was cut into quarters.  The distal aspect of both fallopian tubes were covered with the Interceed, also the left ovary was covered.  This Interceed material was then moistened with Ringer's lactate solution.  Excess carbon dioxide was then evacuated as completely as possible.  The instruments were removed.  The incision sites were sutured with 4-0 Vicryl suture covered with Steri-Strips andr Band-Aids.  The tenaculum was removed from the patient's cervix.  There was no bleeding.  The patient tolerated the procedure well and was transferred to the recovery room.


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Medical Transcription Ob-Gyn Operative Sample Report # 5:

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Postmenopausal bleeding.
2.  Thickened endometrium.

POSTOPERATIVE DIAGNOSES:
1.  Postmenopausal bleeding.
2.  Thickened endometrium.
3.  Submucosal fibroids.
4.  Endometrial polyps.

OPERATION PERFORMED:
Hysteroscopy, D&C.

SURGEON:  John Doe, MD

ASSISTANT:  None.

ANESTHESIA:  General.

ESTIMATED BLOOD LOSS:  Less than 10 mL.

IV FLUIDS:  1 liter.

URINE OUTPUT: 100 mL, clear.

SPECIMENS:  Endometrial curettage.

FINDINGS:  Hysteroscopic findings revealed uterus sounded to 9 cm, submucosal fibroids and polyps noted.

DESCRIPTION OF OPERATION:  The patient was taken to the operating room.  General anesthesia was found to be adequate.  She was then prepped and draped in normal sterile fashion in dorsal lithotomy position.  Under sterile conditions, the patient was straight catheterized and 100 mL of clear urine was obtained.  Examination under anesthesia was performed, difficult to ascertain secondary to the patient's obesity.  Attention was then turned to the patient's perineum, where 2 Sims retractors were used to visualize the cervix.  The anterior lip of the cervix was then grasped with a single-tooth tenaculum.  The uterus was then sounded to 9 cm.  Next, the cervix was dilated in order to accommodate a 5 mm and 30-degree scope.  Hysteroscope was then inserted under direct visualization. Hysteroscopic survey revealed submucosal fibroids and polyps.  Bilateral ostia were difficult to visualize secondary to the fibroids and polyps.  Hysteroscope was then removed under direct visualization.  Endometrial curettage was performed until all quadrants sharp uterine cry was felt.  The submucosal fibroids were palpated during the endometrial curettage.  All instruments were removed from the patient's vagina.  The tenaculum site was noted to be hemostatic.  The patient tolerated this procedure well.  Sponge, lap and needle counts were correct x2.

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Medical Transcription Ob-Gyn Operative Sample Report # 6:

DATE OF OPERATION: 
 
PREOPERATIVE DIAGNOSIS:  Procidentia.
 
POSTOPERATIVE DIAGNOSIS:  Procidentia.
 
OPERATIONS PERFORMED:  Cystoscopy, bilateral ureteral catheterization, vaginal hysterectomy, bilateral salpingo-oophorectomy, repair of cystocele, rectocele and enterocele.
 
SURGEON:  John Doe, MD
 
ASSISTANT:  Jane Doe, PA-C
 
ANESTHESIA:  General.
 
ANESTHESIOLOGIST:  Jill Doe, MD
 
ESTIMATED BLOOD LOSS:  250 mL.
 
OPERATIVE FINDINGS:  Complete eversion and exteriorization of the uterus is present consistent with the diagnosis of procidentia.  Significant cystocele, rectocele and enterocele are present.  A perineal fascia defect is present.  Tuberculations are noted within the urinary bladder.
 
DESCRIPTION OF OPERATION:  In the operating room, under general anesthetic, the patient was prepped and draped in the dorsal lithotomy position.  A weighted speculum was placed and the uterus visualized.  A cystoscope was inserted into the bladder and the bladder distended and inspected.  The bladder wall showed tuberculations.  Both ureteral orifices were detected.  Normal efflux of urine in a peristaltic fashion was seen from the right ureter.  No peristalsis was seen in the left ureter, although the opening was identified and appeared normal.  Using spiral catheters, both ureteral orifices were eventually catheterized and cannulated.  The scope was removed.  The area around the cervical opening was injected with 0.5% Marcaine with epinephrine solution and incised. The vaginal mucosa was pushed away from the cervix.
 
Anteriorly, the supravaginal septum was divided and the bladder retracted anteriorly.  Posteriorly, the cul-de-sac was opened.  On each side, the uterosacral ligaments and peritoneum were clamped, cut and suture ligated.  The anterior peritoneum was opened.  The uterine vessels and cardinal ligaments were clamped, cut and suture ligated.  The lateral attachments to the uterus on each side were clamped, cut and suture ligated.  The bladder was retracted far anteriorly and visualized.  Both ureters were palpated on each side prior to removal of the ovaries.  Each tube and ovary was removed in a stepwise fashion using a Heaney clamp, successfully, to clamp pedicles, which were then cut and suture ligated.  This was performed on each side until both ovaries were removed.  Both ureters were distant from the area of dissection and clamping.
 
The anterior vaginal wall was injected with 0.5% Marcaine with epinephrine solution.  The vaginal mucosa was dissected free from the underlying bladder.  The bladder was dissected free from the mucosa up to its lateral attachments.  Excess vaginal mucosa was trimmed anteriorly and posteriorly.  A large amount of vaginal mucosa was taken.  The bladder was reduced somewhat using pursestring Vicryl suture.  The uterosacral ligaments were identified on both sides using traction.  Using curved Allis clamps, the upper part of the ligament on both sides was grasped.  Ethibond sutures were used to fix this area to the upper part of the vagina on each side.  Both ureters were again palpated throughout this process and in both cases were felt to be at least 2 cm away from the uterosacral ligaments.
 
Cystoscopy was again performed.  The ureteral catheters were removed at this point.  Good efflux was seen from the right with traction on the Ethibond suture.  There appeared to be efflux from the left, which was consistent with the absence of efflux even before the procedure was begun.  The bladder appeared intact.  The scope was removed.  The vaginal cuff was closed using 2 continuous 0 Vicryl sutures tying the Ethibond sutures prior to cuff closure.  A rectal exam at this point confirmed integrity of the mucosa.  The posterior vaginal wall and the perineum were injected with the diluted 0.5% Marcaine with epinephrine solution.  A portion of the perineal skin was removed and the vaginal mucosa dissected free from the rectum in the midline.
 
The deeper structures of the perineum including levators were reapproximated using interrupted Ethibond sutures.  Vaginal mucosa was closed using a running Vicryl suture.  The perineum was closed using a running Vicryl suture.  Rectal exam again confirmed integrity of the mucosa.  Minimal bleeding was encountered.  The patient was repositioned, awakened and then taken to the recovery room in good condition.  All instruments and sponge counts were correct.


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