Medical Specialty:
Neurosurgery
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.
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: neurosurgery, intraventricular hemorrhage, hydrocephalus, intracranial pressure, camino monitor, twist drill, ventriculostomy, hemorrhage, intracranial, pressure, intraventricular,