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The documentation:
Why aren't the atrophic vagina and large cystocele reported?
AGE: 75
SEX: FEMALE
PREOPERATIVE DIAGNOSIS: POSTMENOPAUSAL BLEEDING. ABNORMAL PAP TEST- ENDOMETRIAL CELLS PRESENT
PROCEDURES: ATTEMPTED ENDOMETRIAL CURETTAGE.
POSTOPERATIVE DIAGNOSIS: POSTMENOPAUSAL BLEEDING.
SURGEON: Joshua Kramer, M.D.
FIRST ASSISTANT: ANESTHESIA: GENERAL, ENDOTRACHEAL TUBE
ESTIMATE BLOOD LOSS: LESS THAN 5 CC.
FLUID INPUT: 300 CC OF LR
URINE OUTPUT: 100 CC OF CLEAR URINE.
SPECIMEN: ENDOCERVICAL CURETTAGE.
COMPLICATIONS: NONE.
DISPOSITION: THE PATIENT WAS TAKEN TO THE RECOVERY ROOM IN STABLE CONDITION.
FINDINGS: Atrophic vagina, large cystocele, cervix cannot be visualized and palpated readily.
PROCEDURE: After obtaining informed consent, the patient was taken to the operating room and general anesthesia and endotracheal tube was initiated, the patient was placed in the dorsal lithotomy position. The peritoneum was prepped and draped in sterile fashion. The bladder was drained by straight catheter.
A retractor was placed into the posterior vagina. A right angle retractor was positioned anterior to the cervix. Then the anterior lip of the cervix-cont. with the anterior vaginal wall and very difficult to isolate was grasped with a single-tooth tenaculum. With difficulties endocervical canal localized and endocervical curettage was performed using the Kevorkian curette. Minimal amount of tissue obtained and sent for pathology. Hysteroscopy was not performed due to inability to penetrate internal cervical os. The instruments were removed from the cervix and the vagina. Excellent hemostasis was obtained.
The patient tolerated the procedure well. Sponge counts were correct x 2. Patient was transferred to recovery room in stable condition
____________________________
Joshua Kramer, M.D.
DICTATED BY: J Andrews, M.D.
SEX: FEMALE
PREOPERATIVE DIAGNOSIS: POSTMENOPAUSAL BLEEDING. ABNORMAL PAP TEST- ENDOMETRIAL CELLS PRESENT
PROCEDURES: ATTEMPTED ENDOMETRIAL CURETTAGE.
POSTOPERATIVE DIAGNOSIS: POSTMENOPAUSAL BLEEDING.
SURGEON: Joshua Kramer, M.D.
FIRST ASSISTANT: ANESTHESIA: GENERAL, ENDOTRACHEAL TUBE
ESTIMATE BLOOD LOSS: LESS THAN 5 CC.
FLUID INPUT: 300 CC OF LR
URINE OUTPUT: 100 CC OF CLEAR URINE.
SPECIMEN: ENDOCERVICAL CURETTAGE.
COMPLICATIONS: NONE.
DISPOSITION: THE PATIENT WAS TAKEN TO THE RECOVERY ROOM IN STABLE CONDITION.
FINDINGS: Atrophic vagina, large cystocele, cervix cannot be visualized and palpated readily.
PROCEDURE: After obtaining informed consent, the patient was taken to the operating room and general anesthesia and endotracheal tube was initiated, the patient was placed in the dorsal lithotomy position. The peritoneum was prepped and draped in sterile fashion. The bladder was drained by straight catheter.
A retractor was placed into the posterior vagina. A right angle retractor was positioned anterior to the cervix. Then the anterior lip of the cervix-cont. with the anterior vaginal wall and very difficult to isolate was grasped with a single-tooth tenaculum. With difficulties endocervical canal localized and endocervical curettage was performed using the Kevorkian curette. Minimal amount of tissue obtained and sent for pathology. Hysteroscopy was not performed due to inability to penetrate internal cervical os. The instruments were removed from the cervix and the vagina. Excellent hemostasis was obtained.
The patient tolerated the procedure well. Sponge counts were correct x 2. Patient was transferred to recovery room in stable condition
____________________________
Joshua Kramer, M.D.
DICTATED BY: J Andrews, M.D.
Why aren't the atrophic vagina and large cystocele reported?