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Dr. Andrew Rynne
MD
Dr. Andrew Rynne

Family Physician

Exp 50 years

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What Does This Report Signify?

Location: Inpatient Hospital OPERATIVE REPORT PRE/POSTOPERATIVE DIAGNOSIS: Postmenopausal bleeding with probable polyp seen on saline sonohysterogram. OPERATIVE FINDINGS: Endometrial polyp seen arising from the left cornual region. Otherwise, benign uterine cavity. PROCEDURE: The patient was taken to the operating room and a general anesthetic was administered. The patient was then prepped and draped in the usual manner in lithotomy position and the bladder was emptied with a straight catheter. A weighted speculum was placed to allow for visualization of the cervix, which was grasped anteriorly using single toothed tenaculum. The uterus was then sounded to 9 cm in depth. The cervix was dilated to allow for insertion of the diagnostic hysteroscope. The uterine cavity was then inspected. Immediately apparent was a polyp arising from the left cornual region. Remainder of uterine cavity was inspected and appeared to be benign. Minimal endometrial tissue was otherwise present. At this point then, the hysteroscope was removed and polyp forceps was placed within the uterus. Attempt was made to grasp the polyp but this could not be grabbed with the polyp forceps. Therefore, a sharp curet was used and the polyp was thereby obtained and removed. A small amount of endometrial tissue was also obtained by curettage. Once this had been completed, the hysteroscope was reinserted and the cavity was re-inspected. It was confirmed that the polyp was removed. Otherwise, the endometrial canal then appeared normal. At this point, the procedure was terminated. Tenaculum was removed and good hemostasis was ensured at the cervix. The patient tolerated this procedure well. There were no complications. Fluid in was 325 cc and was equal to fluid out at the end of the procedure. Estimated blood loss was minimal. i need the cpt code
Mon, 1 Apr 2019
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OBGYN 's  Response
Hi,

1) This suggests polyp in the uterine cavity was removed.

Hope I have answered your query. Let me know if I can assist you further.

Take care

Regards,
Dr Soumya, OBGYN
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What Does This Report Signify?

Hi, 1) This suggests polyp in the uterine cavity was removed. Hope I have answered your query. Let me know if I can assist you further. Take care Regards, Dr Soumya, OBGYN