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Pre/post operative diagnosis done. What does the findings suggest?

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, 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 reinspected. 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.
CPT Code: ____________________
ICD-9-CM Code: ____________________
Asked On : Sat, 8 Jun 2013
Answers:  1 Views:  806
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General & Family Physician 's  Response
thanks for using health care magic

You had a uterine mass that was shown to be a polyp. Polyps are benign masses ( non cancerous) that result from over growth of cells in the inner wall of the uterus.

Polyps are a common findings in women and may bleed in some women causing blood to be seen at the level of the vulva like what you experienced.

Its only in very rare cases that polyps could become cancerous. However, since the polyp was excised, that risk has been cancelled.

If you have any further query, Please do not hesitate to let me know.
Best regards
Dr Achuo
Answered: Mon, 10 Jun 2013
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