Reference no: EM133305091
Assignment: PREOPERATIVE DIAGNOSIS: Incomplete abortion with hemorrhage.
INDICATIONS: Kim is a 33-year-old young lady who presents today for D/C after suffering an incomplete spontaneous abortion and she continues to bleed. She understands the risks and complications and I have answered all of her questions concerning future pregnancy and she wishes to proceed at this time with the D/C.
POSTOPERATIVE DIAGNOSIS: Same.
PROCEDURE PERFORMED: Suction dilatation and curettage.
ANESTHESIA: General endotracheal.
ESTIMATED BLOOD LOSS: 150 mL. URINE OUTPUT: 50. FLUIDS: 1000
COMPLICATIONS: None. FINDINGS: Cervical os is open to a size 10 dilator with tissue present at the os.
PROCEDURE: The patient was prepped and draped in the lithotomy position under general endotracheal anesthesia and the bladder was straight cathed. A weighted speculum was placed in the vagina. The anterior lip of the cervix was grasped with a ring forceps. The size 10 curved suction curette was used to evacuate the intrauterine contents. The sharp curette was then used to gently palpate the uterine walls with no return of tissue and the suction curette is used again with negative return of tissue. The ring forceps is removed from the anterior lip of the cervix and the weighted speculum from the vagina. All sponges and needles were accounted for at the completion of the procedure. The patient left the operating room in apparent good condition having tolerated the procedure well. Pathology Report Later Indicated: Benign endocervical and endometrium tissue, abortive tissue.
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