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: Pigtail Catheter Insertion

Description: Left hemothorax, rule out empyema. Insertion of a 12-French pigtail catheter in the left pleural space.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Left hemothorax, rule out empyema.

POSTOPERATIVE DIAGNOSIS: Left hemothorax rule out empyema.

PROCEDURE: Insertion of a 12-French pigtail catheter in the left pleural space.

PROCEDURE DETAIL: After obtaining informed consent, the patient was taken to the minor OR in the Same Day Surgery where his posterior left chest was prepped and draped in a usual fashion. Xylocaine 1% was injected and then a 12-French pigtail catheter was inserted in the medial scapular line about the eighth intercostal space. It was difficult to draw fluid by syringe, but we connected the system to a plastic bag and by gravity started draining at least 400 mL while we were in the minor OR. Samples were sent for culture and sensitivity, aerobic and anaerobic.

The patient and I decided to admit him for a period of observation at least overnight.

He tolerated the procedure well and the postprocedure chest x-ray showed no complications.

Keywords: cardiovascular / pulmonary, chest, pleural space, pigtail catheter, insertion, empyema, hemothorax,
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