Medical Specialty:
Surgery

Sample Name: Pleurocentesis


Description: Ultrasound-guided right pleurocentesis for right pleural effusion with respiratory failure and dyspnea.
(Medical Transcription Sample Report)


PREOPERATIVE DIAGNOSIS: Right pleural effusion with respiratory failure and dyspnea.

POSTOPERATIVE DIAGNOSIS: Right pleural effusion with respiratory failure and dyspnea.

PROCEDURE: Ultrasound-guided right pleurocentesis.

ANESTHESIA: Local with lidocaine.

TECHNIQUE IN DETAIL: After informed consent was obtained from the patient and his mother, the chest was scanned with portable ultrasound. Findings revealed a normal right hemidiaphragm, a moderate right pleural effusion without septation or debris, and no gliding sign of the lung on the right. Using sterile technique and with ultrasound as a guide, a pleural catheter was inserted and serosanguinous fluid was withdrawn, a total of 1 L. The patient tolerated the procedure well. Portable x-ray is pending.


Keywords: surgery, pleural effusion, dyspnea, gliding sign, hemidiaphragm, pleural catheter, pleurocentesis, respiratory, serosanguinous fluid, ultrasound, pleural,