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: Subxiphoid Pericardial Window

Description: Emergent subxiphoid pericardial window, transesophageal echocardiogram.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS (ES):
1. Endocarditis.
2. Status post aortic valve replacement with St. Jude mechanical valve.
3. Pericardial tamponade.

POSTOPERATIVE DIAGNOSIS (ES):
1. Endocarditis.
2. Status post aortic valve replacement with St. Jude mechanical valve.
3. Pericardial tamponade.

PROCEDURE:
1. Emergent subxiphoid pericardial window.
2. Transesophageal echocardiogram.

ANESTHESIA: General endotracheal.

FINDINGS: The patient was noted to have 600 mL of dark bloody fluid around the pericardium. We could see the effusion resolve on echocardiogram. The aortic valve appeared to have good movement in the leaflets with no perivalvular leaks. There was no evidence of endocarditis. The mitral valve leaflets moved normally with some mild mitral insufficiency.

DESCRIPTION OF THE OPERATION: The patient was brought to the operating room emergently. After adequate general endotracheal anesthesia, his chest was prepped and draped in the routine sterile fashion. A small incision was made at the bottom of the previous sternotomy incision. The subcutaneous sutures were removed. The dissection was carried down into the pericardial space. Blood was evacuated without any difficulty. Pericardial Blake drain was then placed. The fascia was then reclosed with interrupted Vicryl sutures. The subcutaneous tissues were closed with a running Monocryl suture. A subdermal PDS followed by a subcuticular Monocryl suture were all performed. The wound was closed with Dermabond dressing. The procedure was terminated at this point. The patient tolerated the procedure well and was returned back to the intensive care unit in stable condition.

Keywords: cardiovascular / pulmonary, endocarditis, valve replacement, st. jude, echocardiogram, transesophageal, pericardium, blake drain, st jude mechanical valve, subxiphoid pericardial window, pericardial window, aortic valve, tamponade, subxiphoid, valve, pericardial, aortic,
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