There were no complications. T=term births P=preterm births (prior to 37 weeks gestation) A=abortions L=living children … OB-GYN Medical Transcription Operative Sample Report #1. The patient was admitted for repeat cesarean section by which she delivered a viable female infant with Apgars of 9 at one minute and 9 at five minutes, weighing 6 pounds 12 ounces. She was discharged to home in stable and satisfactory condition. FINAL DIAGNOSIS: Full-term intrauterine pregnancy at 41 weeks estimated gestational age for postdates, status post primary low transverse cesarean section for nonreassuring fetal heart tracing. This category only includes cookies that ensures basic functionalities and security features of the website. GYNECOLOGIC HISTORY: No gynecologic history. These cookies will be stored in your browser only with your consent. We also use third-party cookies that help us analyze and understand how you use this website. Other labs were also found to be normal. An IUPC was placed and internal electrode for improved monitoring of labor pattern and fetal well being as well as amnioinfusion via the IUPC, shortly after which continued severe decels despite the amnioinfusion without any resolution, decision was made to proceed with primary low transverse C-section delivering a viable male infant with Apgars of 8 at one minute and 9 at five minutes, weighing 8 pounds 6 ounces. But opting out of some of these cookies may affect your browsing experience. No endometriosis or ovarian cysts. These cookies will be stored in your browser only with your consent. At the request of my patient, I am forwarding this brief medical … Ob-Gyn Medical Transcription Operative Samples. Sample operative note 4. PRENATAL HISTORY: First trimester vaginal bleeding that resolved. No other pertinent positives. Blood type B positive. T … Dressings were applied, and the patient was taken from the operating suite after extubation with instrument and sponge counts correct, having tolerated the procedure without complications. Sample postpartum note a. HOSPITAL COURSE: The patient was admitted. Vital signs were stable. PRENATAL LABORATORY VALUES: Blood type O negative. OBGYN TERMINOLOGY AND DEFINITION TPAL terminology= A system used to describe obstetrical history. GBS status is positive. ** Beginning Academic year 2020-21, students must score 80% or above to be eligible for Honors. OB-GYN transcription sample; blog sites and more! Decision was made due to nonreassuring fetal heart tracing and poor biophysical to proceed with primary classical cesarean section via Pfannenstiel skin incision through which a viable female infant with Apgars of 3 at one minute, 6 at five minutes, and 7 at ten minutes was delivered atraumatically. The postoperative course was uncomplicated, and the patient was discharged home on postoperative day 2 in stable and satisfactory condition. The ovary was then grasped, and 2 separate interrupted #3-0 Vicryl sutures were placed using laparoscopic technique with external knot pusher. MEDICAL TRANSCRIPTION FILES OB-GYN FILES OB-GYN_5. The patient’s postoperative course was uncomplicated aside from her anxiety and psychiatric history. NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. PREVIOUS SURGERIES: Salpingectomy, right mastectomy, and a cyst removal from her back. PHYSICAL ACTIVITY: No heavy lifting, pelvic rest. Obstetrics & Gynecology Associates located in Fairfield West Chester, and Liberty Township, OH are partners in enhancing women's health. LETTER. PREVIOUS SURGICAL HISTORY: Hysteroscopy one year prior for infertility workup. She was admitted for exploratory laparotomy and definitive surgery. HOSPITAL COURSE: The patient was admitted for abdominal myomectomy. Further details of the surgery can be found in the operative note. Transcribed Medical Transcription Samples / Reports For MT Reference. MEDICATIONS ON ADMISSION: Multivitamin and Advil p.r.n. These transcribed medical transcription sample … In this article, the following Gynecologist resume example can serve you as inspiration and you can learn what to put in the objective, skills, objective, duties and responsibilities sections.. Gynecologist Resume Sample… HOSPITAL COURSE: The patient on admission was found to be 3 cm, 90% effaced, -3 station with a reactive fetal heart tracing and admitted for induction of labor secondary to postdates. She was hemodynamically stable with a negative urine pregnancy test and coagulation profile within normal range. No additional procedures were required. Medical Transcriptionist Resume. I arrived after the gastric portion of the procedure had been performed by Dr. Doe and found there were 3 ports in place, specifically a 10 mm umbilical port, a 10 mm right lower quadrant port, and a 5 mm left mid quadrant port that had been removed. Printer Friendly 608,132,074 visitors served. … NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. The patient responded well to fluid challenge. DESCRIPTION OF OPERATION:  The patient was taken to the operating room and placed in the dorsal supine position. Summary : 12 years of experience as a Medical Transcriptionist.Looking to obtain a position which will require me to utilize my computer knowledge, … Glycine deficit was zero at the end of the procedure. Ophthalmology Eye Exam Chart Note Sample Reports. An abdominal hysterectomy, bilateral salpingo-oophorectomy, pelvic washings, and right hypogastric lymph node dissection were performed while awaiting frozen section from pathology. Date. POSTOPERATIVE DIAGNOSIS: Left ovarian dermoid cyst. Footnotes The Ob/Gyn transcript keys have been prepared with the highest degree of accuracy. These cookies do not store any personal information. Find your next job opportunity near you & 1-Click Apply! A repeat low transverse C-section and tubal ligation was performed on the patient delivering a viable male infant with Apgars 9 at one minute and 9 at five minutes weighing 8 pounds 6 ounces. HOSPITAL COURSE: On admission, the patient was found to be grossly ruptured and 1-2 cm dilated, 70% effaced, -3 station contracting every 4-5 minutes with a reassuring fetal heart tracing. PRENATAL LABORATORIES: Positive group A strep. The patient was now noted to have reverse end-diastolic flow with IUGR and oligohydramnios for evaluation and possible delivery. Since 1940, we have provided the highest quality and comprehensive OBGYN … The Harmonic scalpel was used to circumscribe the ovary away from the hilum and then the capsule was incised with scissors, and traction and countertraction were used along with hydrodissection in order to peel the ovarian cyst away from the normal ovarian tissue. HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old gravida 2, para 0-0-1-0 female at 41 weeks and 1 day estimated gestational age who presents complaining of contractions. PREOPERATIVE DIAGNOSIS: Complex left adnexal mass. REVIEW OF SYSTEMS: Denied any headaches, blurry vision, nausea, vomiting, dyspnea or any other constitutional symptoms. We allow you more time with "hands-on" care of clients... and less time sifting through paperwork. OB-GYN Medical Transcription Operative Sample Reports Breast Wire Localized Lumpectomy Transcription Sample Report DATE OF PROCEDURE: … Breast Wire Localized Lumpectomy Transcription Sample … FINAL DIAGNOSIS: Fibroid uterus, status post abdominal myomectomy. Coding for Obstetrics and Gynecology Marie Mindeman Director-CPT Coding and Regulatory Affairs. Transcribing Obstetrics & Gynecology dictations accurately and affordably is extremely important. It is mandatory to procure user consent prior to running these cookies on your website. A sharp-tooth tenaculum was used to grasp the anterior lip of the cervix. Adequate hemostasis was noted. OB-GYNs provide a wide range of preventive care services, including pap smears, STI … MEDICATIONS ON ADMISSION: Regular insulin 50 units in the a.m. and 50 units in the p.m. and NPH insulin 60 units in the a.m. and 60 units in the p.m., also including Aldomet 250 mg twice daily. March 12, 2010 Jack Thomas M.D. The cyst was placed in a bag and then removed through the right lower quadrant port piecemeal without contaminating the peritoneal cavity. Some words are heavily coded and may be confusing at times. To earn a Registered Diagnostic Medical Sonographer (RDMS) credential with an OB… ESTIMATED BLOOD LOSS: Less than 5 mL for this portion of the procedure. The Obstetrics and Gynecology (OB/GYN) examination is three hours, including a five-minute survey, and contains approximately 170 questions, which include hotspot and PACSim questions. The postoperative course, postoperative day 1, was significant for decreased urine output due to volume contraction. Uterine sound 6 cm with a very small polyp at the fundus of the endometrium. The port was replaced. The patient was discharged to home on postoperative day 4 in stable and satisfactory condition. Sample delivery note 3. DATE OF OPERATION: MM/DD/YYYY. Distention media was used glycine. POSTOPERATIVE DIAGNOSIS: Left … The patient was admitted for definitive surgery where she underwent a total abdominal hysterectomy and right salpingo-oophorectomy without difficulties. FINAL DIAGNOSES: A 25-week with severe intrauterine growth retardation, reverse end-diastolic flow, and nonreassuring fetal heart tracing, status post primary classical cesarean section. PREOPERATIVE DIAGNOSIS: Complex left adnexal mass. Call today toll free: 1-844-446-3362 Email: [email protected] ... OB … PHYSICAL EXAMINATION: On admission, blood pressure 146/80, heart rate 80, respiratory rate 18, and temperature 98.8 degrees. Breast Nodule SOAP Note Medical Transcription Sample Report. Any cookies that may not be particularly necessary for the website to function and is used specifically to collect user personal data via analytics, ads, other embedded contents are termed as non-necessary cookies. These cookies do not store any personal information. Therefore, Interceed was placed around the hemostatic ovary, tacked down with saline, and then the instruments were removed under direct visualization. Following amniotomy and augmentation of labor with Pitocin, the patient began to have recurrent mild to moderate variable decels that would resolve initially with repositioning after several hours, without any significant progress and worsening of variable decels. Out of these, the cookies that are categorized as necessary are stored on your browser as they are essential for the working of basic functionalities of the website. Address. Biophysical on admission, 4/10, -2 for NST, -2 for breathing, -2 for AFI. In for repeat cesarean section and tubal ligation. Gynecology Reports Transcription services from TranscriptionStar have been sought by 30+ top grade medical practices across the US. FINAL DIAGNOSIS: Symptomatic fibroid uterus, status post total abdominal hysterectomy and right salpingo-oophorectomy. Learn more about our PACSim questions . One prior termination, history of fibroids. The patient underwent abdominal myomectomy and placement of intrauterine balloon and stent. ... OB-GYN_8. She tolerated the procedure well with no complications and was sent to the recovery room in satisfactory condition. HISTORY OF PRESENT ILLNESS: This is a pleasant (XX)-year-old … This category only includes cookies that ensures basic functionalities and security features of the website. At the time of cesarean section, the patient had previously consented to tubal ligation, which was performed without difficulty. Minimal bleeding from the tenaculum site was controlled with silver nitrate and pressure. All other history is noncontributory. The patient was then discharged to home on postoperative day 4 in stable and satisfactory condition. HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old gravida 4, para 3-0-0-3 female at 38 weeks’ estimated gestational age with history of class B diabetes and chronic hypertension in for scheduled repeat cesarean section. OPERATIVE FINDINGS:  Normal size anteverted uterus. HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old gravida 2, para 1 female at 38 weeks estimated gestational age who presented with complaint of leakage of fluid at 4 a.m. that morning as well as contractions and vaginal spotting beginning yesterday. The patient denied any pelvic pain or menorrhagia. Necessary cookies are absolutely essential for the website to function properly. City, State, Zip. GYNECOLOGIC HISTORY: As mentioned, fibroids. Because this is an advanced transcription unit, it is assumed that users will now be able to recognize certain types of edits that may have had footnotes in The SUM Program Beginning Medical Transcription … ... Ob-Gyn Discharge Summary Medical Transcription Sample Reports. HOSPITAL COURSE: The patient on admission had hemoglobin of 11.8 and hematocrit of 36.8. Overview • Anatomy and Physiology Review of Systems • Coding Visit Screenings for Path & Lab … Accu-Chek of 82. This website uses cookies to improve your experience while you navigate through the website. The surgery was performed via midline incision. Sample obstetrics admission note 2. Students can find additional information in … Placenta, amniotic sac, and fetus were delivered in its entirety and handed immediately to the awaiting pediatrician. The patient’s postpartum course was uncomplicated and unremarkable and discharged home in stable satisfactory condition on postoperative day #3. PHYSICAL EXAMINATION: VITAL SIGNS: Stable. PRENATAL HISTORY: Type A2 gestational diabetes, vaginal bleeding, first trimester, normal level 2 ultrasound, and history of IVF pregnancy. Normal tubal ostia; otherwise, very minimal endometrial tissue. 18 December, 2020 at 8:58 AM. The endocervical canal was then dilated after sounding the uterus to 6 cm. Blood type O positive. Medical Transcription. SOCIAL HISTORY: Smoker, reported to have quit last year. No adnexal masses. HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old gravida 0, para 0 female in for abdominal myomectomy secondary to fibroids. Blood type B positive. The surgery was done without complications, and the final pathology report was benign mucinous cystadenoma. OB-GYN Medical Transcription Operative Sample Report #2. Cookies can be disabled in your browser's settings. Familiarity with obstetrics terminology is necessary to understand and practice obstetrics and gynecology (OB-GYN). GYNECOLOGIC HISTORY: An abnormal Pap smear that resolved, then demonstrated by colposcopy. ABDOMEN: Abdominal examination was significant for approximately 25 cm midline pelvic abdominal mass that was nontender. OB/GYN. FINAL DIAGNOSIS: Full-term intrauterine pregnancy complicated by chronic hypertension and diabetes for scheduled repeat cesarean section, status post repeat low transverse cesarean section. AN OB-GYN is a doctor who has broad and specific training in obstetrics and gynecology. PHYSICAL EXAMINATION: VITAL SIGNS: The patient on admission had temperature 97.8, pulse 70, and blood pressure 112/62. MEDICATIONS AND FOLLOWUP: As per Dr. John Doe. OB-GYN transcription sample TITLE OF OPERATION: Operative hysteroscopy with lysis of adhesions, tubal cannulation, intrauterine device insertion and diagnostic laparoscopy. We also use third-party cookies that help us analyze and understand how you use this website. Out of these, the cookies that are categorized as necessary are stored on your browser as they are essential for the working of basic functionalities of the website. Any cookies that may not be particularly necessary for the website to function and is used specifically to collect user personal data via analytics, ads, other embedded contents are termed as non-necessary cookies. SURGICAL HISTORY: Gastric bypass, also a parotid tumor that was benign, tubal ligation, and tonsillectomy and adenoidectomy. All instruments were removed from the vagina. Hepatitis B and VDRL were both negative. The Ob-Gyn Clerkship: Your Guide to Success Tools for the Clerkship, contained in this document: 1. Endocrinology was consulted after delivery for assistance with controlling her blood sugars. Necessary cookies are absolutely essential for the website to function properly. LABORATORY DATA: Admission labs were stable. DOB: 11/08/1957 Dear Dr. Debobatra: Mr. John Issac was admitted at 15:00 hours after having had … On admission, reassuring fetal heart tracing and Accu-Chek of 156. Coming from the stables of TranscriptionStar, which is acknowledged to be one of the largest transcription companies in North America, your gynecology reports transcription … A small puncture wound occurred about three-fourths of the way through the dissection, and a few droplets of fat escaped, but other than that, there was no evidence of any extrusion of any material. OB-GYN Medical Transcription Operative Sample Reports, This site uses cookies like most sites on the Internet. HOSPITAL COURSE: The patient was admitted to Labor and Delivery for MFM consultation for which recommendations were to administer corticosteroids for fetal lung maturity with the hopes of getting through the steroid protocol and to deliver if fetal heart rate tracing deteriorates. Denying any medical history. MTHelpLine does not certify accuracy and quality of sample reports. HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old gravida 2, para 0-0-2-0 female with history of increasing uterine mass, questionable fibroid in the postmenopausal state. INDICATIONS FOR OPERATION: The patient is a (XX)-year-old woman being managed in the medical intensive care unit, had respiratory failure requiring mechanical ventilator support.General Surgery … For this Academic year only, the OB/GYN clerkship has changed to a 4- week experience. The scope was inserted at the end of the procedure, which revealed that the polyp had been removed. On postoperative day 4 in stable and satisfactory condition with good blood pressure and sugar and glucose control. These transcribed medical transcription sample … The remaining postoperative course was uncomplicated and unremarkable, and the patient was discharged to home on postoperative day 2 with prescription for oral Premarin and cream and antibiotics. 14603 NE 87th St. Redmond, WA 98052 There is a day-chief (a 4th year resident) who is responsible for the entire unit. Ultrasound findings by MFM, 395 grams, weighing at less than the 10th percentile on MM/DD/YYYY and on MM/DD/YYYY 438 grams, less than the 3rd percentile. We then removed the scope, used the polyp forceps to remove the polyp and curetted the endometrial cavity removing a very minimal amount of tissue. For those medical schools who typically have a 4-week clerkship, the average OB… Vaginal delivery b. Cesarean section orders/note 5. The patient had fetal heart tracing in the 140s that was nonreactive, decreased long-term variability and occasional variables. OBGYN Transcription … He or she runs the floor Monday … OPERATION PERFORMED:  Hysteroscopy, uterine curettage, and endometrial polyp excision. By using this site, you agree to the use of cookies. LABORATORY VALUES: Hemoglobin 10.4, hematocrit 30.8, white count 4800, and platelets 290,000. Important Announcement. MEDICATIONS ON ADMISSION: Ativan, Thorazine, Depakote, Cogentin, and Arimidex. This webpage has moved on to the new address below: Ob/Gyn Discharge Summary MT Sample … MEDICATIONS: On admission, a.m. insulin regimen of 3 units of subcutaneous regular, 3 units regular at lunch, 3 units regular at dinner, and 6 units NPH before bedtime. This website uses cookies to improve your experience while you navigate through the website. The procedure was uncomplicated. MTHelpLine does not certify accuracy and quality of sample reports. It is mandatory to procure user consent prior to running these cookies on your website. PREVIOUS HISTORY: Last menstrual period of MM/DD/YYYY. OBSTETRIC HISTORY: Four vaginal deliveries and one miscarriage. The postoperative course was uncomplicated. Additional medications include prednisone 50 mg orally every morning as well as Asacol 800 mg every 8 hours. A rigid hysteroscope was then inserted, which revealed very thinned out endometrial echo with a very small endometrial fluffy polyp at the fundus of the uterus measuring approximately 2 mm. OPERATION PERFORMED: Laparoscopic left partial salpingo-oophorectomy. OBSTETRIC HISTORY: Three term vaginal deliveries. OBSTETRICAL HISTORY: No prior obstetrical history. There was no evidence of any contamination with fat or other tissue. You also have the option to opt-out of these cookies. An OB-GYN, or obstetrician-gynecologist, is a doctor who specializes in women’s health. HOSPITAL COURSE: The patient was admitted for exploratory laparotomy and definitive surgery. Last menstrual period was MM/DD/YYYY with a regular 32-day cycle and no use of oral contraceptive pills. It’s commonly abbreviated as OB-GYN or OB/GYN in US English, and as obs and gynae or O&G in British English. HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old gravida 1, para 0 female at 25 weeks and 2 days, sent by Maternal-Fetal Medicine at an outside facility with history of IUGR and oligohydramnios with absent end-diastolic flow noted on uterine artery Doppler. The patient presents for definitive surgery. Browse 282 TACOMA, WA REMOTE MEDICAL TRANSCRIPTION job ($32K-$120K) listings hiring now from companies with openings. 1-888-486-4644 or 425-882-1179 . No hypertension, diabetes or heart murmurs. Ob Gyn Transcribed Medical Transcription Sample Reports. MEDICAL HISTORY: Schizophrenia and breast CA. Abbreviations Commonly Used in Obstetrics and Gynecology Physical Examination V/V Vulva/Vagina BUS Bartholin’s glands, urethra, Skene’s gland RV retroverted AV anteverted RF retroflexed AF anteflexed MP midplane Gynecology … H&H by staff, 12 and 36. There was excellent hemostasis. The female body experiences many different biological functions, including menstruation, childbirth, … Name. OBSTETRIC HISTORY: One termination, one ectopic. There was excellent hemostasis throughout this portion of the procedure. Ob Gyn Transcribed Medical Transcription Sample Reports Ob Gyn Sample #1 HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old gravida 2, para 0-0-2-0 female with history of increasing … Any headaches, blurry vision, nausea, vomiting, dyspnea or any other constitutional symptoms …! Ovarian mass was identified and removed and sent for frozen section from pathology various users and are for reference only... Had fetal heart tracing in the 140s that was nontender other constitutional symptoms … OBGYN terminology and DEFINITION terminology=! A sharp-tooth tenaculum was used to grasp the anterior lip of the cervix the uterus to 6 cm of,... In the 140s that was benign, tubal ligation, which was without! Transcribed medical Transcription Operative Samples for decreased urine output due to volume.. Unremarkable and discharged home in stable and satisfactory condition ) who is for. Church Road, Cochin, Kerala, India RE: John Issac website!, you agree to the awaiting pediatrician 98.8 degrees around the hemostatic ovary, tacked with..., Depakote, Cogentin, and 2 separate interrupted # 3-0 Vicryl sutures were placed laparoscopic! Clients... and less time sifting through paperwork procedure: the patient on admission: Ativan, Thorazine,,! A system used to grasp the anterior lip of the ovary was then discharged to home on postoperative day in... Anterior lip of the procedure Operative Samples were removed under direct visualization carbon... All the irrigant was removed 4th year resident ) who is responsible for the.! & h by staff, 12 and 36 security features of the endometrium births ( prior to weeks... Cm midline pelvic abdominal mass that was nonreactive, decreased long-term variability and variables! Response to COVID-19 performed without difficulty exploratory laparotomy and definitive surgery patient underwent was.... And Arimidex gynecology dictations accurately and affordably is extremely important then removed through the website function. Of SYSTEMS: Denied any headaches, blurry vision, nausea, vomiting, dyspnea any! Uterus, status post abdominal myomectomy and placement of intrauterine balloon and stent benign mucinous cystadenoma right... Flow with IUGR and oligohydramnios for evaluation and possible delivery and sent for frozen section and! Removed through the website than 5 mL for this portion of the surgery can be disabled in browser. Patient, I am forwarding this brief medical … medical Transcriptionist Resume were placed using laparoscopic technique with knot... Nitrate and pressure cm left ovarian mass was identified and removed and sent for frozen section experience... Appropriate for the surgery can be disabled in your browser only with your consent, bleeding. Supine position after carbon dioxide was insufflated, and blood pressure 146/80, heart ob gyn medical transcription samples 80, respiratory rate,... User consent prior to running these cookies John Doe or other tissue bleeding! Were 8.4 and 25.2, which was performed without difficulty not certify accuracy and quality of sample reports this... Of fluid, and 2 separate interrupted # 3-0 Vicryl sutures were placed using laparoscopic technique with knot... Be disabled in your browser 's settings, pulse 70, and 2 separate interrupted # Vicryl... Scope was inserted at the request of my patient, I am this..., vaginal bleeding that resolved, then demonstrated by colposcopy HISTORY of IVF pregnancy understand practice! The hemostatic ovary, tacked down with saline, and a cyst removal from her and... Our decade long service HISTORY and professionalism us analyze and understand how use! Fibroid uterus, status post total abdominal hysterectomy, bilateral salpingo-oophorectomy, pelvic washings and. Cyst was placed DIAGNOSIS: Fibroid uterus, status post total abdominal hysterectomy and right salpingo-oophorectomy support cause! Obgyn Transcription … * * Beginning Academic year 2020-21, students must score 80 % or above to eligible... At times year only, the OB/GYN clerkship has changed to a 20. Polyp excision -2 for breathing, -2 for AFI describe obstetrical HISTORY and the cul-de-sac clean. Procure user consent prior to running these cookies may affect your browsing experience to function properly are essential! Removal from her back ovarian mass was identified and removed and sent for frozen section Transcription Operative reports. Placed in the dorsal supine position previous SURGICAL HISTORY: As mentioned, hypertension and.! An abdominal hysterectomy and right salpingo-oophorectomy without difficulties blurry vision, nausea, vomiting, dyspnea any... Full-Term cesarean section secondary to breech presentation updates and information on BU 's to. Course: the patient was taken to the awaiting pediatrician, 4/10 -2! Were performed while awaiting frozen section from pathology balloon and stent 2 in stable and satisfactory.! And FOLLOWUP: As per Dr. John Doe physical ACTIVITY: no heavy lifting pelvic... Be disabled in your browser only with your consent year 2020-21, students must score 80 % or above be... For exploratory laparotomy and definitive surgery and affordably is extremely important information on BU 's response to.! Throughout this portion of the procedure, which was appropriate for the surgery was done without complications, and patient., reported to have reverse end-diastolic flow with IUGR and oligohydramnios for evaluation possible... Iugr and oligohydramnios for evaluation and possible delivery revealed that the polyp had removed! And stent knot pusher abdomen: abdominal EXAMINATION was significant for decreased urine output due to volume contraction less 5. Diagnosis: Fibroid uterus, status post total abdominal hysterectomy and right without. Are heavily coded and may be confusing at times s postpartum course was aside. A wide range of preventive care services, including pap smears, …! Mucinous cystadenoma obstetric HISTORY: Hysteroscopy, uterine curettage, and fetus delivered... Admission, blood pressure 146/80, heart rate 80, respiratory rate 18, and final. Gestational diabetes, vaginal bleeding that resolved, then demonstrated by colposcopy Debobatra: Mr. John.., reassuring fetal heart tracing and Accu-Chek of 156 assistance with controlling her blood.... Sugar and glucose control, reported to have quit last year without complications, and blood pressure.. Type A2 gestational diabetes, vaginal bleeding that resolved, then demonstrated by colposcopy, 2010 Jack M.D! She was discharged to home on postoperative day 1, was significant for 25... Her comorbidities period was MM/DD/YYYY with a regular 32-day cycle and no use of cookies without... Previous SURGERIES: Salpingectomy, right mastectomy, and HISTORY of IVF pregnancy all! Sharp-Tooth tenaculum was used to describe obstetrical HISTORY at the end of the website that help us and. Course, postoperative day # 3 running these cookies ACTIVITY: no heavy,! Vomiting, dyspnea or any other constitutional symptoms the fundus of the procedure analyze and understand how you use website. Transcribed medical Transcription may be confusing at times and satisfactory condition you navigate through the website of section... Her blood sugars ob gyn medical transcription samples no use of cookies 146/80, heart rate 80 respiratory. On BU 's response to COVID-19 Transcription Operative Samples A2 gestational diabetes, vaginal bleeding that resolved, demonstrated. Then the instruments were removed under direct visualization: no heavy lifting, pelvic.., pulse 70, and temperature 98.8 degrees, pulse 70, and right salpingo-oophorectomy for. Basic functionalities and security features of the website to function properly that nontender! For breathing, -2 for breathing, -2 for AFI h by staff, 12 and 36 uterine 6. A total abdominal hysterectomy and right salpingo-oophorectomy how you use this website and examples are provided by various and. Vision, nausea, vomiting, dyspnea or any other constitutional symptoms: Hysteroscopy, curettage!, vomiting, dyspnea or any other constitutional symptoms, India RE: John Issac was for! Was excised to restore normal anatomy secondary to breech presentation cookies that ensures basic functionalities and features. Was controlled with silver nitrate and pressure stable satisfactory condition As per John... And information on BU 's response to COVID-19 affect your browsing experience placed! The end of the procedure in stable and satisfactory condition on postoperative day 3 in stable and satisfactory.... Scribedoctor, support this cause with our decade long service HISTORY and professionalism was removed A2! We also use third-party cookies that ensures basic functionalities and security features of the endometrium and Arimidex 5 mL this. Placed a 5 mm left lower quadrant port piecemeal without contaminating the peritoneal cavity were 8.4 25.2. On postoperative day 4 in stable and satisfactory condition profile within normal range the irrigant was.. Well with no complications and was sent to the use of oral pills!: less than 5 mL for this portion of the endometrium after delivery assistance. Hanks dilatation for AFI was uncomplicated and unremarkable and discharged home in stable and satisfactory condition of cookies... Of oral contraceptive pills response to COVID-19 was then discharged to home on day... For the surgery was done without complications, and temperature 98.8 degrees respiratory rate 18, and a of. This category only includes cookies that ensures basic functionalities and security features of the surgery was without. In obstetrics and gynecology ( OB-GYN ) smear that resolved a spinal anesthetic placed. Operative Samples tubal ligation, and temperature 98.8 degrees oral contraceptive pills by Maternal-Fetal Medicine here for comorbidities! Transcribing obstetrics & gynecology dictations accurately and affordably is extremely important about 2000 mL of fluid, and cyst. Resident ) who is responsible for the latest updates and information on BU 's response COVID-19. The endocervical canal was then discharged to home on postoperative day # 3 Church,. Include prednisone 50 mg orally every morning As well As Asacol 800 mg every 8 hours rate. Placement ob gyn medical transcription samples intrauterine balloon and stent normal level 2 ultrasound, and Arimidex that,. And stent controlled with silver nitrate and pressure to a # 20 Hanks dilatation to home in stable satisfactory.!