Sample Type / Medical Specialty: Surgery
Sample Name: Chest Tube Insertion
Right hemothorax. Insertion of a #32 French chest tube on the right hemithorax. This is a 54-year-old female with a newly diagnosed carcinoma of the cervix. The patient is to have an Infuse-A-Port insertion.
(Medical Transcription Sample Report)
Right hemothorax.POSTOPERATIVE DIAGNOSIS:
Right hemothorax.PROCEDURE PERFORMED:
Insertion of a #32 French chest tube on the right hemithorax.ANESTHESIA:
1% Lidocaine and sedation.INDICATIONS FOR PROCEDURE:
This is a 54-year-old female with a newly diagnosed carcinoma of the cervix. The patient is to have an Infuse-A-Port insertion today. Postoperatively from that, she started having a blood tinged pink frothy sputum. Chest x-ray was obtained and showed evidence of a hemothorax on the right hand side, opposite side of the Infuse-A-Port and a wider mediastinum. The decision was made to place a chest tube in the right hemithorax to allow for the patient to be stable for transfer out of the operating room.DESCRIPTION OF PROCEDURE:
The area was prepped and draped in the sterile fashion. The area was anesthetized with 1% Lidocaine solution. The patient was given sedation. A #10 blade scalpel was used to make an incision approximately 1.5 cm long. Then a curved scissor was used to dissect down to the level of the rib. A blunt peon was then used to again enter into the right hemithorax. Immediately a blood tinged effusion was released. The chest tube was placed and directed in a posterior and superior direction. The chest tube was hooked up to the Pleur-evac device which was ________ tip suction. The chest tube was tied in with a #0 silk suture in a U-stitch fashion. It was sutured in place with sterile dressing and silk tape. The patient tolerated this procedure well. We will obtain a chest x-ray in postop to ensure proper placement and continue to follow the patient very closely.
surgery, hemothorax, hemithorax, pleur-evac device, infuse-a-port insertion, chest tube, carcinoma,
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