Medical Specialty:
Emergency Room Reports
Sample Name: Chest Tube Insertion in ER
Description: Chest tube insertion done by two physicians in ER - spontaneous pneumothorax secondary to barometric trauma.
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSES:
1. Right spontaneous pneumothorax secondary to barometric trauma.
2. Respiratory failure.
3. Pneumonia with sepsis.
POSTOPERATIVE DIAGNOSES:
1. Right spontaneous pneumothorax secondary to barometric trauma.
2. Respiratory failure.
3. Pneumonia with sepsis.
PROCEDURE: The patient's right chest was prepped and draped in sterile fashion. The site of insertion was anesthetized with 1% Xylocaine, and an incision was made. Blunt dissection was carried out 2 intercostal spaces above the initial incision site. The chest wall was opened, and a 32-French chest tube was placed into the thoracic cavity, after examination with the finger, making sure that the thoracic cavity had been entered correctly. The chest tube was placed.
A postoperative chest x-ray is pending at this time.
The patient tolerated the procedure well and was taken to the recovery room in stable condition.
ESTIMATED BLOOD LOSS: 10 mL
SPONGE COUNT: Correct x2.
Keywords: emergency room reports, spontaneous pneumothorax, barometric trauma, respiratory failure, sepsis, pneumonia, blunt dissection, chest wall, thoracic cavity, chest x-ray, chest tube insertion, chest tube, pneumothorax, tube, chest, insertion,