Sample Type / Medical Specialty: Cardiovascular / Pulmonary
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.

INFORMED CONSENT: Not obtained. This patient is obtunded, intubated, and septic. This is an emergent procedure with 2-physician emergency consent signed and on the chart.

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

COMPLICATIONS: None.

SPONGE COUNT: Correct x2.

Keywords: cardiovascular / pulmonary, 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,