Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples

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Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Transesophageal Echocardiography Probe

Description: Insertion of transesophageal echocardiography probe and unsuccessful insertion of arterial venous lines.
(Medical Transcription Sample Report)

INDICATIONS FOR PROCEDURE: Impending open heart surgery for closure of ventricular septal defect in a 4-month-old girl.

Procedures were done under general anesthesia. The patient was already in the operating room under general anesthesia. Antibiotic prophylaxis with cefazolin and gentamicin was already given prior to beginning the procedures.

PROCEDURE #1: Insertion of transesophageal echocardiography probe.

DESCRIPTION OF PROCEDURE #1: The probe was well lubricated and with digital manipulation, was passed into the esophagus without resistance. The probe was placed so that the larger diameter was in the anterior-posterior position during insertion. The probe was used by the pediatric cardiologist for preoperative and postoperative diagnostic echocardiography. At the end, it was removed without trauma and there was no blood tingeing. It is to be noted that approximately 30 minutes after removing the cannula, I inserted a 14-French suction tube to empty the stomach and there were a few mL of blood secretions that were suctioned. There was no overt bleeding.

PROCEDURE #2: Attempted and unsuccessful insertion of arterial venous lines.

DESCRIPTION OF PROCEDURE #2: Both groins were prepped and draped. The patient was placed at 10 degrees head-up position. A Cook 4-French double-lumen 8-cm catheter kit was opened. Using the 21-gauge needle that comes with the kit, several attempts were made to insert central venous and then an arterial line in the left groin. There were several successful punctures of these vessels, but I was unable to advance Seldinger wire. After removal of the needles, the area was compressed digitally for approximately 5 minutes. There was a small hematoma that was not growing. Initially, the left leg was mildly mottled with prolonged capillary refill of approximately 3 seconds. Using 1% lidocaine, I infiltrated the vessels of the groin both medial and lateral to the vascular sheath. Further observation, the capillary refill and circulation of the left leg became more than adequate. The O2 saturation monitor that was on the left toe functioned well throughout the procedures, from the beginning to the end. At the end of the procedure, the circulation of the leg was intact.

Keywords: cardiovascular / pulmonary, impending open heart surgery, ventricular septal defect, antibiotic prophylaxis, cefazolin, transesophageal echocardiography probe, arterial venous lines, groin, transesophageal echocardiography, echocardiography probe, insertion, transesophageal, arterial, venous, groins, echocardiography, probe,
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