Medical Specialty:
Nephrology
Sample Name: Internal Jugular Vein Catheter Insertion
Description: Acute on chronic renal failure and uremia. Insertion of a right internal jugular vein hemodialysis catheter.
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSES:
1. Acute on chronic renal failure.
2. Uremia.
POSTOPERATIVE DIAGNOSES:
1. Acute on chronic renal failure.
2. Uremia.
PROCEDURE PERFORMED: Insertion of a right internal jugular vein hemodialysis catheter.
BLOOD LOSS: Less than 5 cc.
COMPLICATIONS: None.
HISTORY: The patient is a 74-year-old Caucasian male who presents via direct admission for acute on chronic renal failure with uremia. The patient incidentally was in a car accident ten days ago and has been feeling pretty awful since that time. He is slightly short of breath with mild difficulty in breathing. A pre-procedure x-ray was obtained, which showed no pneumothorax. He did have a significant right pleural effusion and a mild left pleural effusion. We decided to insert the catheter on the right side.
PROCEDURE: The patient was prepped and draped in the usual sterile fashion. 1% lidocaine was used to anesthetize the area two fingerbreadths above the clavicle just posterior to the right sternocleidomastoid muscle and below the external jugular vein. Using the same anesthetic needle, the right internal jugular vein was used to cannulate with good venous blood return. The tract was noted.
Keywords: nephrology, uremia, internal jugular vein hemodialysis catheter, pneumothorax, jugular vein, dialysis, chronic renal failure, internal jugular vein, pleural effusion, hemodialysis catheter, renal failure, cannulate, guidewire, insertion, jugular, catheter, hemodialysis, vein,