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: Chest Tube Placement

Description: Left pleural effusion, parapneumonic, loculated. Left chest tube placement.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Left pleural effusion, parapneumonic, loculated.

POSTOPERATIVE DIAGNOSIS: Left pleural effusion, parapneumonic, loculated.

OPERATION: Left chest tube placement.

IV SEDATION: 5 mg of Versed total given under pulse ox monitoring, 1% lidocaine local infiltration.

PROCEDURE: With the patient semi recumbent and supine the left anterolateral chest was prepped and draped in the usual sterile fashion. A 1% lidocaine was liberally infiltrated into the skin, subcutaneous tissue, deep fascia and the anterior axillary line just below the level of the nipple. The incision was made and deepened through the different layers to reach the intercostal space. The pleura was entered on top of the underlying rib and finger digital palpation was performed. Multiple loculations were encountered. Break up of loculations was performed posteriorly and a chest tube was directed posteriorly. Only a small amount of fluid was noted to come out initially. This was sent for various studies. Soft adhesions were encountered. The plan was to obtain a chest x-ray and start Activase installation.

Keywords: surgery, activase, chest tube placement, pleural effusion, chest tube, lidocaine, infiltration, parapneumonic, loculated, pleural, chest,
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