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: Ventriculostomy Placement

Description: Placement of left ventriculostomy via twist drill. Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure.
(Medical Transcription Sample Report)

PROCEDURE: Placement of left ventriculostomy via twist drill.

PREOPERATIVE DIAGNOSIS: Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure.

POSTOPERATIVE DIAGNOSIS: Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure.

INDICATIONS FOR PROCEDURE: The patient is a man with a history of massive intracranial hemorrhage and hydrocephalus with intraventricular hemorrhage. His condition is felt to be critical. In a desperate attempt to relieve increased intracranial pressure, we have proposed placing a ventriculostomy. I have discussed this with patient's wife who agrees and asked that we proceed emergently.

After a sterile prep, drape, and shaving of the hair over the left frontal area, this area is infiltrated with local anesthetic. Subsequently a 1 cm incision was made over Kocher's point. Hemostasis was obtained. Then a twist drill was made over this area. Bones strips were irrigated away. The dura was perforated with a spinal needle.

A Camino monitor was connected and zeroed. This was then passed into the left lateral ventricle on the first pass. Excellent aggressive very bloody CSF under pressure was noted. This stopped, slowed, and some clots were noted. This was irrigated and then CSF continued. Initial opening pressures were 30, but soon arose to 80 or a 100.

The patient tolerated the procedure well. The wound was stitched shut and the ventricular drain was then connected to a drainage bag.

Platelets and FFP as well as vitamin K have been administered and ordered simultaneously with the placement of this device to help prevent further clotting or bleeding.

Keywords: surgery, intraventricular hemorrhage, hydrocephalus, intracranial pressure, camino monitor, twist drill, ventriculostomy, hemorrhage, intracranial, pressure, intraventricular,
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