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: Mesothelioma - Port-A-Cath Insertion

Description: Biopsy-proven mesothelioma - Placement of Port-A-Cath, left subclavian vein with fluoroscopy.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Mesothelioma.

POSTOPERATIVE DIAGNOSIS: Mesothelioma.

OPERATIVE PROCEDURE: Placement of Port-A-Cath, left subclavian vein with fluoroscopy.

ASSISTANT: None.

ANESTHESIA: General endotracheal.

COMPLICATIONS: None.

DESCRIPTION OF PROCEDURE: The patient is a 74-year-old gentleman who underwent right thoracoscopy and was found to have biopsy-proven mesothelioma. He was brought to the operating room now for Port-A-Cath placement for chemotherapy. After informed consent was obtained with the patient, the patient was taken to the operating room, placed in supine position. After induction of general endotracheal anesthesia, routine prep and drape of the left chest, left subclavian vein was cannulated with #18 gauze needle, and guidewire was inserted. Needle was removed. Small incision was made large enough to harbor the port. Dilator and introducers were then placed over the guidewire. Guidewire and dilator were removed, and a Port-A-Cath was introduced in the subclavian vein through the introducers. Introducers were peeled away without difficulty. He measured with fluoroscopy and cut to the appropriate length. The tip of the catheter was noted to be at the junction of the superior vena cava and right atrium. It was then connected to the hub of the port. Port was then aspirated for patency and flushed with heparinized saline and summoned to the chest wall. Wounds were then closed. Needle count, sponge count, and instrument counts were all correct.

Keywords: surgery, biopsy-proven mesothelioma, placement of port-a-cath, port a cath, subclavian vein, fluoroscopy, mesothelioma,
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