Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Pleurodesis

Description: Chest tube talc pleurodesis of the right chest.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Large recurrent right pleural effusion.

POSTOPERATIVE DIAGNOSIS: Large recurrent right pleural effusion.

PROCEDURE:
1. Conscious sedation.
2. Chest tube talc pleurodesis of the right chest.

INDICATIONS: The patient is a 65-year-old lady with a history of cirrhosis who has developed a recurrent large right pleural effusion. Chest catheter had been placed previously, and she had been draining up to 1.5 liters of serous fluid a day. Eventually, this has decreased and a talc pleurodesis is being done to see her pleural effusion does not recur.

SPECIMENS: None.

ESTIMATED BLOOD LOSS: Zero.

NARRATIVE: After obtaining informed consent from the patient and her daughter, the patient was assessed and found to be in good condition and a good candidate for conscious sedation. Vital signs were taken. These were stable, so the patient was then given initially 0.5 mg of Versed and 2 mg of morphine IV. After a couple of minutes, she was assessed and found to be awake but calm, so then the chest tube was clamped and then through the chest tube a solution of 120 mL of normal saline containing 5 g of talc and 40 mg of lidocaine were then put into her right chest taking care that no air would go in to create a pneumothorax. She was then laid on her left lateral decubitus position for 5 minutes and then turned into the right lateral decubitus position for 5 minutes and then the chest tube was unclamped. The patient was given additional 0.5 mg of Versed and 0.5 mg of Dilaudid IV achieving a state where the patient was comfortable but readily responsive. The patient tolerated the procedure well. She did complain of up to a 7/10 pain, but quickly this was brought under control. The chest tube was unclamped. Now, the patient will be left to rest and she will get a chest x-ray in the morning.

Keywords: cardiovascular / pulmonary, chest tube talc pleurodesis, lateral decubitus position, decubitus position, talc pleurodesis, pleural effusion, chest tube, chest, pleurodesis, talc, recurrent, pleural, effusion, tube,
NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports. These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the preference of the dictating physician. All names and dates have been changed (or removed) to keep confidentiality. Any resemblance of any type of name or date or place or anything else to real world is purely incidental.
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Transcribed Medical Transcription Sample Reports and Examples