Medical Specialty:

Sample Name: Thoracentesis - 1

Description: Thoracentesis, left. Malignant pleural effusion, left, with dyspnea.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Malignant pleural effusion, left, with dyspnea.

POSTOPERATIVE DIAGNOSIS: Malignant pleural effusion, left, with dyspnea.

PROCEDURE: Thoracentesis, left.

DESCRIPTION OF PROCEDURE: The patient was brought to the recovery area of the operating room. After obtaining the informed consent, the patient's posterior left chest wall was prepped and draped in usual fashion. Xylocaine 1% was infiltrated above the seventh intercostal space in the midscapular line. Initially, I tried to use the thoracentesis set after 1% Xylocaine had been infiltrated, but the needle of the system was just too short to reach the pleural cavity due to the patient's very thick chest wall. Therefore, I had to use a #18 spinal needle, which I had to use almost in its entire length to reach the fluid. From then on, I proceeded manually to withdraw 2000 mL of a light milky fluid.

The patient tolerated the procedure fairly well, but almost at the end of it she said that she was feeling like fainting and therefore we carefully withdrew the needle. At that time, it was getting difficult to withdraw fluid anyway and we allowed her to lie down and after a few minutes the patient was feeling fine. At any rate, we gave her bolus of 250 mL of normal saline and the patient returned to her room for additional hours of observation. We then thought that if she was doing fine, then we will send her home.

A chest x-ray was performed after the procedure which showed a dramatic reduction of the amount of pleural fluid and then there was no pneumothorax or no other obvious complications of her procedure.

Keywords: surgery, malignant pleural effusion, chest wall, pleural effusion, dyspnea, thoracentesis, fluid, pleural,