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: Cholecystostomy Tube Placement

Description: Placement of cholecystostomy tube under ultrasound guidance. Acute acalculous cholecystitis.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Acute acalculous cholecystitis.

POSTOPERATIVE DIAGNOSIS: Acute acalculous cholecystitis.

PROCEDURE: Placement of cholecystostomy tube under ultrasound guidance.

ANESTHESIA: Xylocaine 1% With Epinephrine.

INDICATIONS: Patient is a pleasant 75-year-old gentleman who is about one week status post an acute MI who also has acute cholecystitis. Because it is not safe to take him to the operating room for general anesthetic, I recommended he undergo the above-named procedure. Procedure, purpose, risks, expected benefits, potential complications, and alternative forms of therapy were discussed with him and he was agreeable to surgery.

TECHNIQUE: Patient was identified, then taken to the Radiology suite, where the area of interest was identified using ultrasound and prepped with Betadine solution, draped in sterile fashion. After infiltration with 1% Xylocaine and after multiple attempts, the gallbladder was finally cannulated by Dr. Kindred using the Cook 18-French needle. The guidewire was then placed and via Seldinger technique, a 10-French pigtail catheter was placed within the gallbladder, secured using the Cook catheter method, and dressings were applied and patient was taken to recovery room in stable condition.

Keywords: surgery, under ultrasound guidance, cholecystostomy tube, acalculous cholecystitis, catheter, cholecystostomy, ultrasound, acalculous, cholecystitis,
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