Patient Name: _______________
Patient ID: _______________
Date: _______________
Operation: Dilation and Curettage
Surgeon: _______________
Assistants: _______________
Anethesia: General anesthesia with endotrachial tube
Anesthesiologist: _______________
Pre-Op Diagnosis: Abnormal Uterine Bleeding
Post-Op Diagnosis: Same
Procedure:

1. D & C

Operative Findings:

1. Normal bimanual exam, anteverted uterus. No adnexal massess palpable
2. Moderate endometrial tissue from curettage

Estimated Blood Loss: 100 cc
Complications: None.

Clinical Note:
Ms. _______________ is a __ year-old female who presented to the office with abnormal uterine bleeding. Ultrasound imaging did not reveal any submucosal fibroids or polyps. An attempt at endometrial biopsy was performed in the office but only scant material was obtained. Risks, potential complications, alternatives, and benefits were discussed with Ms. _______________ and consent was signed prior to the OR.

Procedure:
Under general anaesthetic in a dorsal lithotomy position, the patient was prepped and draped in the usual sterile manner. Bimanual exam prior to prepping revealed a mobile, anteverted non-enlarged uterus. An in and out catheterization was performed. A weighted speculum was placed in the vagina and with the help of a right angle retractor the anterior lip of the cervix was grasped with a single toothed tinaculum and brought forward. Taking care not to perforate the uterus, a sound was passed inside to measure the length of the uterus. A series of Hegar dilators were then inserted sequentially into the cervical os up to a size of 8 mm. The smallest curette available was then used to perform the curettage. In a sequential order, being sure to cover all regions of the uterine cavity, sweeps with the curette were performed to obtain tissue. Following this, a clamp was gentle introduced into the cavity, closed, and brought out in an attempt to obtain any remaining tissue or grasp any possible polyps. Only small fragments of tissue were returned. The tissue samples were collected and sent to pathology. The tenaculum was then removed and the cervix examined for hemostasis which was achieved. Finally the weighted speculum was removed. The patient tolerated the procedure well and was brought to the recovery room in a stable condition. At the end of the procedure all sponges and instruments were counted and correct. The blood loss was minimal and there were no complications.