Dilation and Curettage Operative Report LOCATION: Inpatient,

Dilation and Curettage Operative Report LOCATION: Inpatient, Hospital PATIENT: Sandy Porter PRIMARY CARE PHYSICIAN: Andy Martinez, MD SURGEON: Andy Martinez, MD PREOPERATIVE DIAGNOSIS: Dysfunctional uterine bleeding. POSTOPERATIVE DIAGNOSIS: Dysfunctional uterine bleeding. PROCEDURE PERFORMED: Dilation and curettage of the uterus and diagnostic hysteroscopy. SURGICAL INDICATIONS: This patient is a 38-year-old female whose last delivery was a little over a year ago. She started having periods every 2 weeks over the past few months. She had recently had what was thought to be a false-positive serum HCG level at greater than 91,000. A urine HCG was negative, and a second sample sent to the Paradise Valley Clinic was negative. She had an ultrasound, which showed slight irregularity in the uterine cavity. OPERATIVE FINDINGS: The uterus is 8.5 cm deep. There was a very slight irregularity along the posterior aspect of the endometrial cavity; however, this was possibly just due to grooving from the dilation process. No definite polyps were noted. The tubal ostia were both seen easily. OPERATIVE DESCRIPTION: After induction of spinal anesthesia, the patient was placed in the dorsal lithotomy position. The perineum and vagina were prepped, bladder straight catheterized, and the patient draped. Bimanual exam was carried out and uterus was anterior and normal size. Adnexa revealed no masses. A weighted speculum was placed in the vagina and the cervix grasped with a single-tooth tenaculum. The endocervical canal was dilated to 7 mm with Hegar dilators. The 5.5-mm Olympus hysteroscope was introduced using normal saline as the distention medium. Photographs were taken of the endometrial cavity. The hysteroscope was withdrawn, and the sharp endometrial curettage was done. Hysteroscope was reinserted and no sign of perforation was seen. The endometrium looked fragmented. Blood loss estimation was 5 cc. Specimen to pathology: Endometrial curettings. The patient tolerated the procedure well except for an incident during the prep when some of the Betadine prep solution apparently splashed up into the patient’s eye. This was washed out by anesthesia. CPT Code(s): ICD-10-CM Code(s):

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