DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Left persistent pneumothorax.
POSTOPERATIVE DIAGNOSIS:
Left persistent pneumothorax.
OPERATION PERFORMED:
Left tube thoracostomy.
SURGEON: John Doe , MD
ANESTHESIA: Morphine,
fentanyl, 1% lidocaine with epinephrine.
ESTIMATED BLOOD LOSS:
Minimal.
INDICATIONS FOR PROCEDURE:
The patient is a (XX)-year-old female who fell and had an injury to her
chest. The patient went to the emergency
room where a left-sided chest tube was placed for a pneumothorax. The patient
was transferred to this facility. The patient had a persistent pneumothorax,
despite the left-sided chest tube. The pneumothorax became larger as seen on
chest x-ray. Therefore, the patient was recommended to have a new left chest
tube placed. The patient was educated on the risks, benefits and alternatives and
agreed to undergo this procedure.
DESCRIPTION OF PROCEDURE:
The patient was in the supine position on her bed. The patient's left
arm was restrained above her head. The dressings from the preexisting chest
tube were removed. The chest was then prepped and draped in the usual sterile
manner. Lidocaine 1% was injected several centimeters above the previously
placed chest tube on the mid axillary line above the level of the nipple. An incision
was made with a #11 blade measuring approximately 2 to 3 cm long. The
underlying tissues were dissected bluntly with a clamp and superiorly down to
the chest wall. More 1% lidocaine was injected into the pleura and the
underlying soft tissues. A Kelly clamp was used to puncture the pleura just
above the rib and this was spread. A finger was inserted into the chest cavity
and the lung was palpated. Any adhesions between the lung and the chest wall
were taken down bluntly. Following this, a 36-French chest tube was placed in
the chest cavity. It was then secured in place with a 2-0 silk suture and 3-0
nylon U stitch was placed. Sterile dressings were applied. The chest tube was
placed to suction. A chest x-ray was
ordered for confirmation of placement.
