1-888-486-4644 or 425-882-1179 . At the request of my patient, I am forwarding this brief medical … An OB-GYN, or obstetrician-gynecologist, is a doctor who specializes in women’s health. The patient was admitted for definitive surgery where she underwent a total abdominal hysterectomy and right salpingo-oophorectomy without difficulties. Address. No adnexal masses. There were no complications. One prior termination, history of fibroids. Uterine sound 6 cm with a very small polyp at the fundus of the endometrium. SOCIAL HISTORY: Smoker, reported to have quit last year. At the time of cesarean section, the patient had previously consented to tubal ligation, which was performed without difficulty. 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… OB-GYN transcription sample TITLE OF OPERATION: Operative hysteroscopy with lysis of adhesions, tubal cannulation, intrauterine device insertion and diagnostic laparoscopy. The scope was inserted at the end of the procedure, which revealed that the polyp had been removed. 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. ** Beginning Academic year 2020-21, students must score 80% or above to be eligible for Honors. Necessary cookies are absolutely essential for the website to function properly. The cyst was placed in a bag and then removed through the right lower quadrant port piecemeal without contaminating the peritoneal cavity. DESCRIPTION OF PROCEDURE: After appropriate informed consent was obtained, the patient was taken to the operating suite, given general endotracheal anesthesia, and then prepped and draped in the usual sterile fashion in the dorsal supine position with a Foley catheter in place. FINAL DIAGNOSIS: Fibroid uterus, status post abdominal myomectomy. This website uses cookies to improve your experience. Sample obstetrics admission note 2. 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. 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. Learn more about our PACSim questions . PREVIOUS HISTORY: Last menstrual period of MM/DD/YYYY. You also have the option to opt-out of these cookies. HOSPITAL COURSE: The patient was admitted for exploratory laparotomy and definitive surgery. A sharp-tooth tenaculum was used to grasp the anterior lip of the cervix. 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. MEDICATIONS AND FOLLOWUP: As per Dr. John Doe. The surgery was performed via midline incision. This category only includes cookies that ensures basic functionalities and security features of the website. The surgery was done without complications, and the final pathology report was benign mucinous cystadenoma. POSTOPERATIVE DIAGNOSIS: Left ovarian dermoid cyst. City, State, Zip. The postoperative course was uncomplicated, and the patient was discharged to home on postoperative day 3 in stable and satisfactory condition. These transcribed medical transcription sample … Gentlemen. But opting out of some of these cookies may affect your browsing experience. By using this site, you agree to the use of cookies, Pharyngitis SOAP Note Medical Transcription Sample Report, Attempted Vacuum Extraction Sample Report, Hysteroscopy and Endometrial dilation Curettage Sample Report, Pelvic Pain and Dysuria Chart Note MT Sample Report, Bartholin’s Cyst Marsupialization Operative Sample Report, Cesarean Section Medical Transcription Sample Report, Pomeroy Postpartum Tubal Ligation Sample Report. Gynecology Reports Transcription services from TranscriptionStar have been sought by 30+ top grade medical practices across the US. Important Announcement. OPERATION PERFORMED:  Hysteroscopy, uterine curettage, and endometrial polyp excision. 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. There was no evidence of any contamination with fat or other tissue. She tolerated the procedure well with no complications and was sent to the recovery room in satisfactory condition. OB-GYN Medical Transcription Operative Sample Reports, This site uses cookies like most sites on the Internet. Visit Back2BU for the latest updates and information on BU's response to COVID-19. 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 … No history of pelvic infections. 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. Endocrinology was consulted after delivery for assistance with controlling her blood sugars. Overview • Anatomy and Physiology Review of Systems • Coding Visit Screenings for Path & Lab … These cookies do not store any personal information. 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. But opting out of some of these cookies may affect your browsing experience. OPERATION PERFORMED: Laparoscopic left partial salpingo-oophorectomy. Postoperative hemoglobin and hematocrit were 8.4 and 25.2, which was appropriate for the surgery that the patient underwent. By using this site, you agree to the use of cookies. Since 1940, we have provided the highest quality and comprehensive OBGYN … T=term births P=preterm births (prior to 37 weeks gestation) A=abortions L=living children … MEDICATIONS ON ADMISSION: Multivitamin and Advil p.r.n. On postoperative day 4 in stable and satisfactory condition with good blood pressure and sugar and glucose control. Coding for Obstetrics and Gynecology Marie Mindeman Director-CPT Coding and Regulatory Affairs. Vaginal delivery b. Cesarean section orders/note 5. PHYSICAL ACTIVITY: No heavy lifting, pelvic rest. It is mandatory to procure user consent prior to running these cookies on your website. MEDICAL HISTORY: As mentioned, hypertension and diabetes. To earn a Registered Diagnostic Medical Sonographer (RDMS) credential with an OB… Date. Examination under anesthesia revealed findings described above. The patient was then discharged to home on postoperative day 4 in stable and satisfactory condition. Cookies can be disabled in your browser's settings. 14603 NE 87th St. Redmond, WA 98052 MTHelpLine does not certify accuracy and quality of sample reports. AN OB-GYN is a doctor who has broad and specific training in obstetrics and gynecology. The patient underwent abdominal myomectomy and placement of intrauterine balloon and stent. Accu-Chek of 82. Therefore, copious irrigation was undertaken with about 2000 mL of fluid, and all the irrigant was removed. No hypertension, diabetes or heart murmurs. The patient’s postoperative course was uncomplicated aside from her anxiety and psychiatric history. 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 … MEDICATIONS ON ADMISSION: Ativan, Thorazine, Depakote, Cogentin, and Arimidex. The patient was now noted to have reverse end-diastolic flow with IUGR and oligohydramnios for evaluation and possible delivery. Ophthalmology Eye Exam Chart Note Sample Reports. 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. Minimal bleeding from the tenaculum site was controlled with silver nitrate and pressure. 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. POSTOPERATIVE DIAGNOSIS: Left … Vital signs were stable. Transcribing Obstetrics & Gynecology dictations accurately and affordably is extremely important. The patient was discharged to home on postoperative day 4 in stable and satisfactory condition. Ob-Gyn Medical Transcription Operative Samples. The postoperative course was uncomplicated, and the patient was discharged home on postoperative day 2 in stable and satisfactory condition. GYNECOLOGIC HISTORY: As mentioned, fibroids. FINAL DIAGNOSIS: Full-term intrauterine pregnancy complicated by chronic hypertension and diabetes for scheduled repeat cesarean section, status post repeat low transverse cesarean section. OBGYN Transcription … LABORATORY DATA: Admission labs were stable. These cookies do not store any personal information. Find your next job opportunity near you & 1-Click Apply! Additional medications include prednisone 50 mg orally every morning as well as Asacol 800 mg every 8 hours. 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. This webpage has moved on to the new address below: Ob/Gyn Discharge Summary MT Sample … Biophysical on admission, 4/10, -2 for NST, -2 for breathing, -2 for AFI. The postoperative course was unremarkable. Printer Friendly 608,132,074 visitors served. GYNECOLOGIC HISTORY: No gynecologic history. 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. REVIEW OF SYSTEMS: Denied any headaches, blurry vision, nausea, vomiting, dyspnea or any other constitutional symptoms. 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. FINAL DIAGNOSIS: A 25 cm benign mucinous cystadenoma of the left adnexa, status post total abdominal hysterectomy and bilateral salpingo-oophorectomy via midline incision. We also use third-party cookies that help us analyze and understand how you use this website. OB-GYN Medical Transcription Operative Sample Reports Breast Wire Localized Lumpectomy Transcription Sample Report DATE OF PROCEDURE: … Breast Wire Localized Lumpectomy Transcription Sample … PHYSICAL EXAMINATION: On admission, blood pressure 146/80, heart rate 80, respiratory rate 18, and temperature 98.8 degrees. 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 … OBGYN TERMINOLOGY AND DEFINITION TPAL terminology= A system used to describe obstetrical history. March 12, 2010 Jack Thomas M.D. Placenta, amniotic sac, and fetus were delivered in its entirety and handed immediately to the awaiting pediatrician. HOSPITAL COURSE: The patient on admission had hemoglobin of 11.8 and hematocrit of 36.8. This website uses cookies to improve your experience while you navigate through the website. ABDOMEN: Abdominal examination was significant for approximately 25 cm midline pelvic abdominal mass that was nontender. The ovary was then grasped, and 2 separate interrupted #3-0 Vicryl sutures were placed using laparoscopic technique with external knot pusher. The port was replaced. The endocervical canal was then dilated after sounding the uterus to 6 cm. GBS status is positive. 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. The postoperative course was uncomplicated. 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. OB-GYN Medical Transcription Operative Sample Report #2. PHYSICAL EXAMINATION: VITAL SIGNS: Stable. Last menstrual period was MM/DD/YYYY with a regular 32-day cycle and no use of oral contraceptive pills. Annual GYN Exam Medical Transcription Sample Reports. DOB: 11/08/1957 Dear Dr. Debobatra: Mr. John Issac was admitted at 15:00 hours after having had … 18 December, 2020 at 8:58 AM. PRENATAL LABORATORY VALUES: Hemoglobin 9.4. Blood type B positive. PRENATAL HISTORY: Type A2 gestational diabetes, vaginal bleeding, first trimester, normal level 2 ultrasound, and history of IVF pregnancy. I placed a 5 mm left lower quadrant port through a stab wound under direct visualization after carbon dioxide was insufflated. It’s commonly abbreviated as OB-GYN or OB/GYN in US English, and as obs and gynae or O&G in British English. No additional procedures were required. 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. 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