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: Port Insertion

Description: Port insertion through the right subclavian vein percutaneously under radiological guidance. Metastatic carcinoma of the bladder and bowel obstruction.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSES
1. Metastatic carcinoma of the bladder.
2. Bowel obstruction.

POSTOPERATIVE DIAGNOSES
1. Metastatic carcinoma of the bladder.
2. Bowel obstruction.

PROCEDURE: Port insertion through the right subclavian vein percutaneously under radiological guidance.

PROCEDURE DETAIL: The patient was electively taken to the operating room after obtaining an informed consent. A time-out process was followed. Antibiotics were given. Then, the patient's right deltopectoral area was prepped and draped in the usual fashion. Xylocaine 1% was infiltrated. The right subclavian vein was percutaneously cannulated without any difficulty. Then using the Seldinger technique, the catheter part of the port, which was a single-lumen port, was passed through the introducer under x-ray guidance and placed in the junction of the superior vena cava and the right atrium.

A pocket had been fashioned and a single-lumen drum of the port was connected to the catheter, which had been trimmed and affixed to the pectoralis fascia with couple of sutures of Vicryl. Then, the fascia was closed using subcuticular suture of Monocryl. The drum was aspirated and irrigated with heparinized saline and then was put in the pocket and the skin was closed. A dressing was applied including the needle and the port with the catheter so that the floor could use the catheter right away.

The patient tolerated the procedure well and was sent to recovery room in satisfactory condition. A chest x-ray was performed that showed that there were no complications of procedure and that the catheter was in right place.

Keywords: surgery, metastatic carcinoma of the bladder, percutaneously, subclavian vein, port insertion, metastatic carcinoma, bowel obstruction, 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