Over 500 Medical Transcription Sample Reports For Medical Transcriptionists!!

Left Tube Thoracostomy Procedure Transcription Sample Report

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.