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Report 4
Name: Barbara Thomas
#050102
Date of Operation:
Department: OB-GYN Surgery
Surgeon: M. Makabuhay, MD
Assistant Surgeon: Jones, MD
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OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS
Molar gestation.
POSTOPERATIVE DIAGNOSIS
Hydatidiform mole.
PRIMARY PROCEDURE
SUCTION AND DILATATION AND CURETTAGE.
ANESTHESIA
Mask.
FINDINGS
Examination under anesthesia demonstrated an approximately 16-week-size uterus without any
adnexal masses. Post procedure there was scant vaginal bleeding, and the uterus was
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approximately 10-12 weeks’ size, firm, without any extending adnexal masses.
PROCEDURE
After the induction of adequate mask anesthesia, the patient was placed in the dorsal supine
lithotomy position. The cervix was dilated to 3 cm with a #20 Hanks dilator. Using a suction
curet, suction curettage was performed. Sharp curettage was performed to complete the
procedure. The uterus sounded to 13 cm. The curettage yielded some small vesicles and a
moderate amount of tissue. A specimen consisting of products of curettage was sent to
pathology. Medications consisted of Pitocin 30 units in the IV bag and Methergine 0.2 mg given
IM. The patient tolerated the procedure well. IV fluids: 550 mL of crystalloid. Estimated blood
loss: 300 mL.
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Marikit Makabuhay, MD
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Footnotes
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Write out date here per Rule 64.
Per the patient and doctor list, there are two Dr Jones, Bill and Anne. Since the doctor did not specify which Dr
Jones, flag it.
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Rule 40 for possessive of time.
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Rule 27.
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Curette is also an acceptable spelling for this.
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Rule 2.
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Rule 3.
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Rule 2.
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