Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Emergency Room Reports
Sample Name: Chest Tube Insertion in ER

Description: Chest tube insertion done by two physicians in ER - spontaneous pneumothorax secondary to barometric trauma.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSES:
1. Right spontaneous pneumothorax secondary to barometric trauma.
2. Respiratory failure.
3. Pneumonia with sepsis.

POSTOPERATIVE DIAGNOSES:
1. Right spontaneous pneumothorax secondary to barometric trauma.
2. Respiratory failure.
3. Pneumonia with sepsis.

INFORMED CONSENT: Not obtained. This patient is obtunded, intubated, and septic. This is an emergent procedure with 2-physician emergency consent signed and on the chart.

PROCEDURE: The patient's right chest was prepped and draped in sterile fashion. The site of insertion was anesthetized with 1% Xylocaine, and an incision was made. Blunt dissection was carried out 2 intercostal spaces above the initial incision site. The chest wall was opened, and a 32-French chest tube was placed into the thoracic cavity, after examination with the finger, making sure that the thoracic cavity had been entered correctly. The chest tube was placed.

A postoperative chest x-ray is pending at this time.

The patient tolerated the procedure well and was taken to the recovery room in stable condition.

ESTIMATED BLOOD LOSS: 10 mL

COMPLICATIONS: None.

SPONGE COUNT: Correct x2.

Keywords: emergency room reports, spontaneous pneumothorax, barometric trauma, respiratory failure, sepsis, pneumonia, blunt dissection, chest wall, thoracic cavity, chest x-ray, chest tube insertion, chest tube, pneumothorax, tube, chest, insertion,
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