Tulane Greenbook

## **Sample Dictations**

Postoperative Diagnosis: same as preoperative diagnosis s/p [spontaneous/operative] vaginal delivery
Procedure Performed: [spontaneous/operative] vaginal delivery
Indication (HPI): Patient is a X year old G\_\_P\_\_ who presented to labor and delivery at X weeks with \_\_\_. She was admitted in anticipation of delivery. Her labor course was augmented/induced with \_\_\_, and was otherwise [un]complicated.
Infant findings and Apgar score: viable [fe]male infant with Apgars of \_\_ and \_\_
Procedure in Detail: I was at the bedside of this X year old G\_\_P\_\_ at X weeks gestational age in active labor when the vaginal exam was completely dilated, completely effaced and [+2/+3] station. The patient was placed in dorsal lithotomy position and prepared and draped in the normal fashion. Under continuous [external/internal] fetal heart rate monitoring, the patient was encouraged to push. With good maternal effort, she delivered a viable [fe]male infant with Apgars of \_\_ and \_\_.
The fetal head delivered first in [ROA/LOA/OP] position. Nuchal cord was [reduced/cut/not present]. Then, with gentle downward motion, the [L/R] anterior fetal shoulder was delivered, followed by the [L/R] posterior fetal shoulder, followed by the remainder of the infant without difficulty. The umbilical cord was clamped x 2 and cut in between [by the baby’s father]. The infant was vigorous and placed on the mother’s abdomen/handed to awaiting nurses/pediatric team.
Cord blood [was/and gasses were] then collected. The placenta delivered [spontaneously/manually] and intact. Three-vessel cord was noted. Uterine massage and oxytocin IV were given until the fundus was firm.
The cervix, perineum, vagina, and rectum were then carefully inspected for lacerations. [None were noted/what types and the repairs performed].  Hemostasis was noted.
No sponges were left in the vagina and all counts were correct. Mother and baby were bonding well at the end of the procedure. Dr. Attending was present for the entire delivery.

Postoperative Diagnosis: same as preoperative diagnosis s/p procedure performed
Procedure(s) Performed: [primary/repeat] [low transverse/classical] cesarean delivery with [Pfannenstiel/vertical midline] incision [and bilateral tubal ligation]
Indication (HPI): Patient is a X year old G\_\_P\_\_ who presented to labor and delivery at X weeks gestational age for [ ].
1. Viable [male/female] infant with Apgars of \_\_ and \_\_
2. Grossly normal appearing uterus, fallopian tubes, ovaries

Procedure in Detail: The patient was taken to the operating room. After adequate anesthesia, patient was prepped and draped in the normal sterile fashion in the dorsal supine position with a leftward tilt. A time-out was performed.
A Pfannenstiel incision was made with the knife and the incision was taken down to the level of the rectus fascia with [knife/Bovie cautery]. The fascia was incised and the incision was extended laterally [with Mayo scissors/Bovie]. The peritoneal cavity was bluntly entered and the incision was extended (with Metzenbaum scissors). The bladder blade was then inserted. The vesicouterine peritoneum was tented up and entered sharply with Metzenbaum scissors and extended laterally. The bladder flap was created digitally. The bladder blade was then replaced.
A low transverse incision was made into the uterus, and extended laterally with finger fraction (or bandage scissors). The vertex was elevated. The remainder of the infant was then delivered without difficulty. Mouth and nares were suctioned. The cord was clamped and cut, and the baby was handed to the pediatric team in attendance. The infant received Apgar scores of X at 1 minute and X at 5 minutes.
The placenta was delivered (spontaneously or manually). The uterus was cleared of all clots and debris. The uterus was [delivered through the incision/left in for repair]. The incision was closed with chromic suture in a locking fashion. [Then a second layer of chromic suture imbricating the first.] Hemostasis was noted.
Inspection of the pelvic cavity revealed grossly normal tubes and ovaries. [*Dictate BTL here.*] The abdomen was thoroughly irrigated and suctioned of all irrigation and blood clots. The uterus was returned to the abdominal cavity. [The bladder flap was closed with a running suture of 2-0 chromic.] The parietal peritoneum was closed with a running layer of 2-0 chromic suture. The fascia was closed with 0 Vicryl suture. The subcutaneous tissue was reapproximated with 2.0 plain gut. The skin was closed with [staples/INSORB/Monocryl suture in a subcuticular fashion].
Sponge, lap and needle counts were correct x 2. Patient tolerated the procedure well and was taken to recovery in stable condition. Dr. Attending was present and scrubbed for the entire procedure.

1. Hysteroscopy D&C
2. Endometrial ablation
3. [All other procedures]

Indication (HPI): Patient is a X year old G\_\_P\_\_ with [abnormal uterine bleeding/other diagnosis] who presented to Lakeside for her scheduled hysteroscopy D&C. Consents were reviewed and she agreed to proceed with planned procedure.
1. Normal appearing external female genitalia
2. Normal appearing cervix without lesions
3. Uterus sounded to \_\_ cm
4. Hysteroscopy revealed \_\_\_
5. Hemostasis noted at end of case

Specimens:
1. Endometrial curetting
2. [Endometrial polyp]

Complications:
Procedure in Detail: The patient was taken to the operating room where anesthesia was obtained without difficulty.  The patient was placed in the dorsal lithotomy position and prepped and draped in a normal fashion.  The bladder was emptied with a straight catheter. A time-out was performed.
A weighted/bivalve speculum was placed in the posterior vagina and a right angle retractor was used to retract the anterior vagina.  The cervix was visualized and grasped with a tenaculum for retraction. [The uterus was sounded to \_\_ cm.] The cervix was then gently serially dilated to \_\_ mm using Hegar dilators.
The hysteroscope was inserted through the cervical os and the endometrial cavity was visualized.  A [proliferative/secretory/atrophic]-appearing endometrium was noted. The tubal ostia were visualized bilaterally. [The TruClear device was inserted through the hysteroscope and a polypectomy/myomectomy was performed on \_\_. Total run time was \_\_. Total deficit was \_\_.] The hysteroscope was removed, and sharp curettage of the endometrium was then performed. The specimen was sent for pathologic diagnosis.
[Novasure ablation: The cervix was sounded to \_\_ cm. The endometrial cavity length was \_\_ cm. The Novasure device was set up as per packaged instructions and inserted into the uterus.  The array was deployed. The endometrial cavity width was \_\_ cm. These values were entered into the Novasure machine, and a power of \_\_ was calculated. The intracavitary assessment was performed and successfully passed. The device was then activated and ablation performed for \_\_ seconds. The device was removed from the uterus. A hysteroscoe was again inserted into the uterus and burned endometrium was seen.
All instruments were removed from the vagina. Hemostasis was noted throughout. All counts were correct. The patient was taken to the recovery room in stable condition. Dr. Attending was present and scrubbed for the entire procedure.

2. Rh [positive/negative]

Postoperative Diagnosis: same as preoperative diagnoses s/p procedures performed
Procedure Performed: suction D&C
Indication (HPI): Patient is a X year old G\_\_P\_\_ who presented to [clinic/Lakeside ED] with \_\_. Ultrasound revealed evidence of [incomplete/missed/inevitable/septic] abortion at approximately \_\_ weeks gestational age. After discussion of risks, benefits, alternatives, decision was made to proceed to OR for suction D&C.
1. Normal appearing external female genitalia
2. Uterus palpated to \_\_ weeks size on bimanual exam
3. Cervix dilated to \_\_ cm
4. Material removed from uterus appropriate for approximate gestational age
5. Uterus palpated to \_\_ weeks size at conclusion of procedure
6. Hemostasis noted at end of case

Specimens:
1. Products of conception

Complications:
Procedure in Detail: The patient was taken to the operating room where anesthesia was obtained without difficulty.  200mg doxycycline was given IV. The patient was placed in the dorsolithotomy position and prepped and draped in the normal fashion. Bladder was emptied with a straight catheter. A time-out was performed.
A weighted speculum was placed in the posterior vagina and a right angle retractor used to retract the anterior vagina. The cervix was visualized and grasped with a tenaculum for traction. The cervix was then gently, serially dilated to \_\_ mm using Hegar dilators. [The uterus was gently sounded to 9 cm.] A \_\_ mm suction curette advanced gently to the uterine fundus. The suction device was then activated and the curette rotated to clear the uterus of products of conception. A sharp curettage was then performed until a gritty texture was noted. The suction curette was then reintroduced  to clear the uterus of all remaining products of conception.
All instruments were removed from the cervix.  Hemostasis was noted.  The speculum was then removed from the vagina. Sponge, lap and needle counts were correct times two. The patient tolerated the procedure well and was taken to the recovery room in stable condition. Patient is Rh [negative/positive] and [did/did not] require Rhogam at the conclusion of the procedure.
Dr. Attending was scrubbed and present for the entire procedure.

2. Undesired fertility

Postoperative Diagnosis: same as preoperative diagnosis s/p procedure(s) performed
Procedure(s) Performed:
1. Diagnostic laparoscopy
2. [Lysis of adhesions]
3. Tubal ligation with [Kleppinger bipolar device/Filshie clips/Fallope ring]

Indication (HPI): Patient is a X year old G\_\_P\_\_ with [diagnosis]. After discussion of risks, benefits, alternatives, decision was made to proceed to OR for scheduled diagnostic laparoscopy [and BTL]. She understood that BTL is a permanent, nonreversible procedure and was informed of all other options for contraception including long-acting reversible methods. She expressed desire to proceed with BTL.
1. Normal appearing external female genitalia
2. Uterus sounded to \_\_ cm
3. Grossly normal appearing uterus, fallopian tubes, ovaries
4. [Describe adhesions or other intraabdominal findings]
5. Smooth liver edge noted
6. Appendix [grossly normal appearing/not well visualized]
7. Hemostasis noted at end of case

Procedure in Detail: After successful induction of general anesthesia, the patient was placed in the lithotomy position. Abdomen, perineum, and vagina were prepped and draped in a routine fashion. A time-out was performed.  The urinary bladder was catheterized with a Foley catheter and emptied.
Bimanual examination was performed. Uterus was normal in size and [retroverted/anteverted]. No adnexal masses were palpated.
The weighted speculum was placed in the posterior vaginal. A right angle retractor was used to retract the anterior vaginal wall. The cervix was visualized and grasped with the single-toothed tenaculum. The uterine cavity was sounded to \_\_ cm and was regular. The cervix was dilated to \_\_ mm using Hegar dilators and a HUMI device was inserted for uterine manipulation. Attention was then turned to the abdomen for laparoscopy.
[VERESS ENTRY] A \_\_ mm [vertical] incision was made immediately below the umbilicus. The Veress needle was passed through the incision into the peritoneal cavity and the peritoneal cavity was insufflated with carbon dioxide. The incision was then extended and a \_\_ mm trocar was passed. The laparoscope was inserted into the abdominal cavity through the trocar. Uterus, fallopian tubes, and ovaries were identified and all were grossly normal appearing. The [anterior and] posterior cul-de-sac was evaluated and was grossly normal.
[OPEN ENTRY] A 1 cm incision was made below the umbilicus with the knife and carried through to the underlying fascia with blunt dissection. The fascia was grasped with Kocher clamps x2 and entered sharply with curved Mayo scissors. The Hassan trocar was then inserted into the peritoneum and placement was confirmed with the laparoscope. Pneumoperitoneum was obtained with 3L carbon dioxide.
An anterior puncture was performed [RLQ/LLQ incision was made] and a 5 mm trocar was introduced.
[KLEPPINGER] Through the trocar, the bipolar forceps were passed. The [left/right] fallopian tube was visualized and followed to its fimbriated end. The tube was grasped in the center and this segment cauterized until the ampmeter read 0. Grasping proximally next to it, another segment was cauterized. The [right/left] fallopian tube was then visualized and followed to its fimbriated end. The same procedure was completed on this tube. [The scissors were then passed and the tubes were cut on each side, and the ends again coagulated.] Hemostasis was noted.
[FILSHIE/FALLOPE] Through the trocar, the [Filshie clip/Fallope ring] applicator was passed. The patient’s [left/right] fallopian tube identified and followed out to the fimbriated end. The [Filshie clip/Fallope ring] was applied in the mid-isthmic area with a good knuckle noted and good blanching at the site of the application. There was no bleeding in the mesosalpinx. The same procedure was then completed on the [right/left] tube in a similar fashion.
Intraabdominal survey was performed with the findings as noted above. The pneumoperitoneum and the instruments were removed from the abdominal cavity [under direct visualization]. The skin was closed with 4-0 Monocryl.  All instruments were then removed from the vagina. Hemostasis was noted throughout. [The Foley catheter was removed at the conclusion of the procedure.]
The patient tolerated the procedure well and was taken to the recovery room in stable condition. Dr. Attending was scrubbed and present for the entire procedure.

Procedure in Detail: The patient was taken to the operating room, where LMA anesthesia was obtained without difficulty. The patient was prepped and draped in the normal sterile fashion in the dorsal lithotomy position.  A time-out was performed.
A weighted speculum was placed into the posterior fornix and a curved Deaver was placed into the anterior fornix. Two sutures of 0 Vicryl were used to ligate the cervical branches of the cervical artery at the 3 and 9 o'clock positions in a figure-of-eight suture. Then, the cervix was injected with 1% Lidocaine with epinephrine. Lugol solution was applied to the cervix, and (no decreased uptake was noted/decreased uptake was noted at \_\_\_\_).
Cold-knife conization was then performed with a scapel.  The specimen was amputated, and a stitch was placed at the 12 o'clock position for orientation. Next, endocervical curettage was performed with Kevorkian curette.
The base of the cervical cone specimen was then cauterized using Bovie cautery. The margins of the cone specimen were also cauterized in a similar manner (or A 0-vicryl suture was placed in a running, locking fashion around the margins of the cone site.). The cone site was noted to be hemostatic.
Surgicel was then placed into the cervical cone site. The stay sutures were cut.  The vagina was packed with Kerlex gauze. All the instruments removed from the patient's vagina.
All sponge, lap and needle counts were correct x 2. The patient tolerated the procedure well, was awakened and transferred to the recovery room in stable condition.
Dr. Attending was present and scrubbed for the entire procedure.

Procedure in Detail: The patient was taken to the operating room where spinal/epidural anesthesia was obtained without difficulty and noted to be adequate.  A time out was performed. The patient was then positioned on the operating table in the dorsal lithotomy position with the legs supported using stirrups. The perineum was then prepped and draped in the usual sterile fashion.
A bimanual exam was performed and the uterus was noted to be X week size with no palpable masses. The cervix was noted to be X cm dilated with X% effacement.  A weighted/lateral/bivalve speculum was inserted into the vagina and the cervix was visualized.
(If advanced cervical dilation with prolapsing of membranes: The membranes were noted to be prolapsing through the cervical os. Membranes were reduced by placing a 30 mL Foley through the cervix and inflating the balloon to displace the membranes cephalad.)
The anterior lip of the cervix was visualized and grasped using ring forceps. A 5 mm Mersilene fiber suture was used to take a bite in the body of the cervix at the 12 o’clock position as close as possible to the junction of the rugated vaginal epithelium exiting at the X o’clock position. (Repeat description of successive bites identifying the location of each bite.) The purse-string suture was tightened and tied X times.  The knot was noted to be at the X o’clock position. (If Foley was placed earlier:  The Foley was gradually deflated and removed as the cerclage was tightened.)
The speculum was removed from the vagina and a bimanual exam was performed. The cervix was noted to be closed/finger tip/X cm dilated with the cerclage knot palpable at the X o’clock position.
All needle, sponge, and instrument counts were noted to be correct x 2 at the completion of  the procedure.  The patient tolerated the procedure well and was transferred to the recovery room in stable condition.
Dr. Attending was present and scrubbed for the entire procedure.

Procedure in Detail: After general anesthesia was obtained, the patient was prepped and draped in the normal sterile fashion.  A time-out was performed.  A Foley catheter was inserted. A Pfannenstiel skin incision was made with the knife and carried through to the underlying layer of fascia. The fascia was incised, and the incision extended transversely. The rectus muscles were separated and the peritoneum tented up with hemostats and entered sharply.  The incision was extended with good visualization of the bowels and bladder. Inspection of the pelvic cavity revealed the findings as noted above.  The O'Sullivan-O'Connor retractor was then placed. The bowels were then packed away with moist lap pads.
A thyroid tenaculum (or Kelly clamps) were used to retract the uterus. The round ligaments were bilaterally clamped, cut and suture ligated. The anterior leaf of the broad ligament was then incised anteriorly to the midline from both sides  to create the bladder flap.   The bladder flap was gently dissected down with a sponge stick (or sharply dissected).  The infundibulopelvic ligaments were bilaterally clamped, cut and suture ligated. The uterine blood vessels skeletonized and were bilaterally clamped, cut and suture ligated. A 0 Vicryl was used throughout the case. Approximately 4 bites were necessary on either side of the cervix to go down and take the cardinal ligament and paracervical tissue to reach the uterosacral ligaments.  The uterosacral ligaments were then doubly clamped and suture ligated.  Using two Heaney clamps, the vagina was clamped under the cervix and the vaginal mucosa then entered sharply with Mayo/Jorgenson scissors.  The uterus and cervix were then amputated.
Angle sutures were placed bilaterally, incorporating the posterior vaginal mucosa, the anterior vaginal mucosa and the cardinal ligament stump. The vaginal cuff was then closed with interrupted figure of eight sutures.
The pelvis was irrigated with saline and the pedicles  each examined and hemostasis noted.   Attention was then directed to closure of the abdomen.
The peritoneum was closed with a running suture of 3-0 Vicryl. The rectus muscle approximated with a interrupted suture of 2-0 Vicryl. The fascia was closed with 2 separate running sutures of 0 Vicryl starting laterally and tied separately in the midline. The wound was irrigated. The subcutaneous tissue approximated with a running suture of 2-0 plain gut and the skin closed with staples/subcuticular stitch.
Sponge, lap and needle count were correct times 2.  The patient was awoken from anesthesia and taken to recovery in stable condition.
Dr. Attending was scrubbed and present for the entire procedure.

·  VAGINAL HYSTERECTOMY
·  ANTERIOR COLPORRHAPHY
·  KELLY PLICATION OF THE URETHRA
·  POSTERIOR COLPOPERINEORRHAPHY
With the patient under general anesthesia in the dorsolithotomy position, she was prepped and draped in the usual manner.  A time-out was performed. Bimanual examination was performed with the findings as noted above.
(Labia minora were sutured to the labia majora, using silk sutures on each side.)  A weighted speculum was placed in the posterior vagina, and the cervix was grasped with a toothed tenaculum.  The cervical mucusa was then injected with dilute (Xylocaine, lidocaine w/ epinephrine) in a circumferential manner.
An incision was made circumferentially around the cervical vaginal junction with the knife/Bovie, after which the cervical vaginal mucosa was pushed upward and the bladder dissected off.   The anterior cul-de-sac was then entered sharply and the posterior cul-de-sac was entered sharply also without difficulty.
The right and then the left uterosacral ligaments were doubly clamped with a Heaney clamp, then suture ligated with #0 vicryl.   The Cardinal ligaments were then doubly clamped and suture ligated bilaterally.  Hemostasis was noted.
The uterine arteries and broad ligaments were then serially clamped with Heaney clamps, transected and suture ligated on both sides.  Both cornua, the infundibulopelvic ligaments were clamped, transected and suture ligated.  Hemostasis was noted.
(Alternate: The uterus was then delivered posteriorly, after which double clamps were placed across the right medial portion of the right broad ligament, ovarian ligament, middle portion of the fallopian tube, and another clamp was placed across the lower portion of the broad ligament, including the round ligament. This too was doubly clamped, after which the right side of the uterus was freed. )
The ovaries were palpated and found to be normal.  The peritoneum was closed with a purse string suture of 2-0 Vicryl, after the weighted speculum had been removed. Ties on the uterosacral ligaments were tied together as well as ties across the round ligaments on each side. These were then tied to each other, so that there were contralateral and ipsilateral tying. In this way, the pedicles were exteriorized and hemostasis was noted to be obtained.
Cystocele repair/Kelly plication:  Two Allis clamps were then placed at the base of the cystocele. Another Allis clamp was placed at the apex of the cystocele. The anterior vaginal mucosa was then incised at the midline to the Allis clamp at the apex of the cystocele. The vaginal mucosa was then dissected by sharp and blunt dissection from the underlying tissue. Bleeding was encountered laterally, which was controlled using figure-of-eight sutures of 2-0 Vicryl. A series of mattress sutures of 2-0 Vicryl were then taken in order to imbricate the cystocele. Two Kelly plication sutures of 2-0 Vicryl were then taken, and this gave good support to the urethra. A Foley catheter was then inserted into the urethra and urine was noted to be clear. The catheter was inserted easily without any evidence of obstruction.
Excess anterior vaginal mucosa was then excised, after which the anterior vagina was approximated using interrupted sutures of 2-0 Vicryl. Hemostasis was noted to have been obtained.
Rectocele repair:  Attention was then turned to the posterior wall. Two Allis clamps were placed at the mucocutaneous junction in the region of the fourchette, and another clamp was placed at the apex of the rectocele. The tissue between the distal 2 clamps and the region of fourchette was excised, and carefully measured so that the introitus would be a 3-finger introitus. The posterior vaginal mucosa was then incised in the midline by sharp and blunt dissection. The posterior vaginal mucosa was then dissected to the level at the Allis clamp at the apex of the rectocele. The posterior vaginal mucosa was dissected with blunt and sharp dissection from the underlying tissue. The rectocele was then imbricated using mattress sutures of 2-0 Vicryl. Two sutures of 0 Vicryl were then taken in the levator ani musculature. The excess posterior vaginal mucosa was then excised, after which the posterior vaginal mucosa was approximated using interrupted sutures of 2-0 Vicryl. The stitches in the levator ani muscle were then tied in the midline, after which the closure of the posterior vaginal mucosa was continued using 2-0 Vicryl. The perineal muscles were then approximated in the midline in layers, using 2-0 Vicryl, after which the perineal skin was approximated using interrupted sutures of 2-0 Vicryl.  Hemostasis was noted to be present.
Lap, sponge, instrument and needle count were reported to be correct. A finger was inserted into the rectum, and no stitches were present in the rectum. A 2-inch iodoform gauze was packed into the vagina. The Foley catheter was noted to be draining clear at the close of the procedure. The patient was awoken from anesthesia and taken to recovery in stable condition.
Dr. Attending was scrubbed and present for the entire procedure.