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Tracheostomy Medical Transcription Sample Report

DATE OF OPERATION:
MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Respiratory failure.

POSTOPERATIVE DIAGNOSIS:
Respiratory failure.

OPERATION PERFORMED:
Tracheostomy.

SURGEON:
John Doe, MD

ASSISTANT:
None.

ANESTHESIOLOGIST:
Jane Doe, MD

INDICATIONS FOR PROCEDURE:
The patient is a (XX)-year-old female in the ICU with sepsis related to pseudomembranous colitis.  She underwent total abdominal colectomy approximately seven days ago.  She has failed to wean from the ventilator.  She has had problems with pulmonary toilet due to an indwelling endotracheal tube, and it was thought that tracheostomy would be in her best interest.

Consent was obtained from the family, understanding the risks and benefits and the following procedure was performed today.

BLOOD LOSS:
Zero.

COMPLICATIONS:
None.

FINDINGS:
Thick secretions within the trachea.  Excellent oxygenation and CO2 return following tracheostomy insertion.

DESCRIPTION OF PROCEDURE:
The patient was brought directly from the ICU to the operating room.  The patient was given light intravenous sedation and the area over the neck was prepped and draped in usual sterile fashion.  Lidocaine 1% with epinephrine was used to infiltrate the skin and subcutaneous tissue.

A transverse incision was made one fingerbreadth above the suprasternal notch and dissection taken down through the platysma to the strap muscles, which were divided in the midline.  Hemostasis was excellent.  Dissection continued through the thyroid gland, which was thin and atrophic and the pretracheal fascia was cauterized.  A box-type incision was made in the second tracheal ring and the trachea was opened.  The endotracheal tube was slid back and dense secretions were aspirated.  A #6 low-pressure cuff Shiley tracheostomy tube was successfully inserted into the trachea and the balloon inflated.

The patient was then ventilated successfully with excellent oxygen saturations and CO2 return.  Saline was instilled into the trachea and pulmonary toilet ensued.  The tracheostomy tube was secured to the skin using 3-0 Prolene suture.  A tracheostomy tape was used to secure the flange around the neck leaving two fingerbreadths space beneath the tape.  Stay sutures used to secure the trachea were taped to the skin in the event of accidental extubation.  Sterile dressing was applied.  Hemostasis was excellent throughout the case.  Needle and sponge counts were correct at the end.  The patient was moved back to the intensive care unit directly in critical but stable condition.