Medical Transcription Sample Reports

Over 500 Medical Transcription Sample Reports For Medical Transcriptionists!!

PEG Tube Placement Transcription Sample Report

DATE OF PROCEDURE:   MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Inability to eat.

POSTOPERATIVE DIAGNOSIS:  Inability to eat.

PROCEDURE PERFORMED:  Percutaneous endoscopic gastrostomy tube placement.

SURGEON:  John Doe, MD

ANESTHESIA:  IV sedation.

ESTIMATED BLOOD LOSS:  Zero.

TUBES:  20-French Ponsky PEG tube to gravity drainage.

COMPLICATIONS:  None.

INDICATIONS FOR PROCEDURE:  The patient is a (XX)-year-old female who was recently hospitalized after sustaining a cerebrovascular accident secondary to dysfunction from this. She has been unable to take adequate nutrition by mouth. After a discussion between the family and the neurology service, it was felt that a G-tube would be appropriate to aid in her recovery and to maintain enteral access. She now presents for this procedure. Prior to beginning the procedure, we met with the family and discussed the procedure, complications, risks, benefits, and alternatives.

DESCRIPTION OF PROCEDURE:   On the day of the procedure, the patient was taken to the endoscopy suite. She was placed in 30 degrees head-up position. A time-out was held, and the patient and the planned procedure were confirmed with all those present. She was placed on pulse oximetry and a monitor as well as nasal cannula oxygen. She was sedated with divided doses of fentanyl and Versed. She received a total of 100 mcg of fentanyl and 3 mg of Versed throughout the procedure, which allowed for excellent sedation.

Once an adequate level of sedation was reached, a bite block was placed, and her esophagus was intubated. We then passed the GE junction and entered the stomach. We continued the endoscopy out to the first portion of the duodenum. There were no ulcers present. A retroflexed view of the GE junction revealed a small hiatal hernia. The light from the endoscope was readily visible through the patient's anterior abdominal wall, 2 cm inferior to the left costal margin. This transilluminated quite easily. A single finger impulse was seen briskly through the gastroscope as well. The patient's epigastrium was then prepped with Betadine and draped in a standard sterile fashion. We used a local needle to infiltrate the skin over the proposed PEG site first. This was infiltrated with a wheal of lidocaine. The local needle was then used to enter the stomach. Suction was held on this as it was used to enter the stomach, and we saw no air or succus or stool prior to entering the gastric lumen. Local was then infiltrated as we withdrew the needle along the path of this.

A small stab incision was then made, and the introducer needle was then placed while aspirating into the gastric lumen. Again, no air, succus or stool was noted prior to visualizing the tip of the needle in the gastric lumen. The guidewire was then placed through the introducer needle. This was grasped and was withdrawn through the patient's mouth. This was then attached to a #20 Ponsky PEG tube, which was then pulled in an antegrade manner into the stomach and out the anterior abdominal wall. The esophagus was reentered better with the gastroscope, and this was advanced into the stomach. The tube at 2.5 cm was noted to be not too tight or not too loose but to appear just right without any blanching of the gastric mucosa. It appeared it spun easily as well. It was secured at this depth, then cut to size, and placed to gravity drainage.

The stomach was then desufflated, and the endoscope was then withdrawn along the length of the esophagus. The patient tolerated the procedure well, and with supplemental oxygen, remained with saturations greater than 95% throughout the procedure. There were no complications. The patient was then taken to the recovery room in stable condition.