Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Surgery
Sample Name: Ventricular Drain Catheter Insertion

Description: Burr hole and insertion of external ventricular drain catheter.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSES: Increased intracranial pressure and cerebral edema due to severe brain injury.

POSTOPERATIVE DIAGNOSES: Increased intracranial pressure and cerebral edema due to severe brain injury.

PROCEDURE: Burr hole and insertion of external ventricular drain catheter.

ANESTHESIA: Just bedside sedation.

PROCEDURE: Scalp was clipped. He was prepped with ChloraPrep and Betadine. Incisions are infiltrated with 1% Xylocaine with epinephrine 1:200000. He did receive antibiotics post procedure. He was draped in a sterile manner.

Incision made just to the right of the right mid pupillary line 10 cm behind the nasion. A self-retaining retractor was placed. Burr hole was drilled with the cranial twist drill. The dura was punctured with a twist drill. A brain needle was used to localize the ventricle that took 3 passes to localize the ventricle. The pressure was initially high. The CSF was clear and colorless. The CSF drainage rapidly tapered off because of the brain swelling. With two tries, the ventricular catheter was then able to be placed into the ventricle and then brought out through a separate stab wound, the depth of catheter is 7 cm from the outer table of the skull. There was intermittent drainage of CSF after that. The catheter was secured to the scalp with #2-0 silk suture and the incision was closed with Ethilon suture. The patient tolerated the procedure well. No complications. Sponge and needle counts were correct. Blood loss is minimal. None replaced.

Keywords: surgery, intracranial pressure, cerebral edema, external ventricular drain catheter, ventricular drain catheter, brain injury, burr hole, ventricular, brain, catheter,
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