DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Large right pleural effusion.
POSTOPERATIVE DIAGNOSIS: Large right pleural effusion.
PROCEDURE PERFORMED: Ultrasound-guided right thoracentesis with catheter.
SURGEON: John Doe, MD
DESCRIPTION OF PROCEDURE: After informed consent, the patient was prepared with sterile chlorhexidine and the area of the pleural effusion located by ultrasound. Subcutaneous anesthesia was applied to the skin and deeper tissue with 1% lidocaine. The pleural fluid was easily located with a 20-gauge spinal needle. After this, a small skin incision was made with a scalpel and the long catheter passed in the pleural space over a longer needle. Subsequently, a total of 1950 mL of clear to slightly cloudy yellow pleural fluid was removed. The patient tolerated the procedure well. There were no immediate complications.
Sample #2
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Respiratory insufficiency.
2. Hypoxemia.
3. Right pleural effusion.
POSTOPERATIVE DIAGNOSES:
1. Respiratory insufficiency.
2. Hypoxemia.
3. Right pleural effusion.
OPERATION PERFORMED: Right thoracentesis.
CONSENT: Consent was obtained from the patient prior to the procedure being performed after the risk and benefits were explained to her.
MEDICATIONS: Lidocaine 1%, approximately 4 mL.
COMPLICATIONS: No complication was noted.
ESTIMATED BLOOD LOSS: None noted.
DESCRIPTION OF PROCEDURE: The patient was prepped and draped in the sterile fashion. She was placed in a sitting position at the side of her bed, leaning over her beside table. Ultrasound technologist did localize the right pleural space, and there was noted to be a large right pleural effusion. The patient’s left pleural space was also examined with no evidence of any pleural effusion. Using the Arrow thoracentesis kit, approximately 2250 mL of serous fluid was removed from the patient’s right pleural space. The patient tolerated the procedure well.
Post procedure, a chest radiograph is to be performed. The pleural fluid was sent to the laboratory for cell count and differential, cytopathology, Gram stain, culture and sensitivity, AFB culture, fungal culture, glucose, protein, albumin, LDH, amylase, and pH analysis.
Sample #3
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Right pleural effusion.
POSTOPERATIVE DIAGNOSIS: Right pleural effusion.
PROCEDURE PERFORMED: Right-sided thoracentesis.
FINDINGS:
1. 1350 mL of clear yellow blood removed.
2. Fluid sent for cytology, microbiology, and chemistry.
DESCRIPTION OF PROCEDURE: The patient was placed in a seated, upright position, and his right posterior chest was prepped and draped. Then, 1% lidocaine was used as local anesthetic. Along the posterior axillary line, a finder needle was introduced into the right chest and clear yellow fluid was removed. A larger needle was then placed into the right thoracic cavity, and through this needle, a catheter was advanced. The catheter was then connected to a suction bottle and a total of 1350 mL of clear yellow fluid was removed. The patient tolerated the procedure well. When all the fluid had stopped draining, the catheter was removed, and hemostasis was secured with direct pressure. A Band-Aid was placed. The specimens were sent for chemistry, cytology, and microbiology. The patient’s followup chest x-ray is pending at this time.
