Medical Report: Diagnosis of Recurrent Pneumothorax
OPERATIVE REPORT
Patient Name: J. Randy Rolen
Patient ID: 115037
Date of Surgery: 12/13/----
Admitting Physician: Leon Medina, MD, Internal Medicine
Surgeon: Simon Williams, MD, Pulmonary/Thoracic Surgery
Preoperative Diagnosis: Recurrent right pneumothorax.
Postoperative Diagnosis: Same.
Operative Procedure: Right chest tube thoracostomy, pleura drainage.
Anesthesia: Xylocaine 1%.
Specimen Removed: Pleural fluid sent for cytology.
INDICATIONS: This 61-year-old white male presents with recurrent pneumothorax on the right and increasing subcutaneous emphysema, despite earlier insertion of two small caliber chest tubes. Also, interval change in position of the right lower chest tube catheter has been noted radiographically.
DESCRIPTION OF PROCEDURE: Patient was placed in the lateral dicubidous position. The right hemithorax was prepared with Betadine solution and draped off with sterile towels and drapes in the usual manner.
Xylocaine 1% was used for local infiltration as well as intercostal nerve block. A 2 cm transverse incision in approximately the sixth intercostal space were sharply incised through the skin and subcutaneous tissue down to intercostal muscle. Muscles were separated with a blunt curved hemostat, and the pleural space was drained. A #24 French chest tube was inserted bluntly and posteriorly to 8 cm, secure to the skin with 2-0 silk, dressed with a gauze dressing, and secured to the skin with adhesive tape
(Continued)
OPERATIVE REPORT
Patient Name: J. Randy Rolen
Patient ID: 115037
Date of Surgery: 12/13/----
Page 2
and benzoin. Patient tolerated the procedure without incident. Estimated operating time was 15 minutes.
_________________________
Simon Williams, MD
Pulmonary/Thoracic Surgery
SW:
D:12/13/----
T:12/13/----
Patient Name: J. Randy Rolen
Patient ID: 115037
Date of Surgery: 12/13/----
Admitting Physician: Leon Medina, MD, Internal Medicine
Surgeon: Simon Williams, MD, Pulmonary/Thoracic Surgery
Preoperative Diagnosis: Recurrent right pneumothorax.
Postoperative Diagnosis: Same.
Operative Procedure: Right chest tube thoracostomy, pleura drainage.
Anesthesia: Xylocaine 1%.
Specimen Removed: Pleural fluid sent for cytology.
INDICATIONS: This 61-year-old white male presents with recurrent pneumothorax on the right and increasing subcutaneous emphysema, despite earlier insertion of two small caliber chest tubes. Also, interval change in position of the right lower chest tube catheter has been noted radiographically.
DESCRIPTION OF PROCEDURE: Patient was placed in the lateral dicubidous position. The right hemithorax was prepared with Betadine solution and draped off with sterile towels and drapes in the usual manner.
Xylocaine 1% was used for local infiltration as well as intercostal nerve block. A 2 cm transverse incision in approximately the sixth intercostal space were sharply incised through the skin and subcutaneous tissue down to intercostal muscle. Muscles were separated with a blunt curved hemostat, and the pleural space was drained. A #24 French chest tube was inserted bluntly and posteriorly to 8 cm, secure to the skin with 2-0 silk, dressed with a gauze dressing, and secured to the skin with adhesive tape
(Continued)
OPERATIVE REPORT
Patient Name: J. Randy Rolen
Patient ID: 115037
Date of Surgery: 12/13/----
Page 2
and benzoin. Patient tolerated the procedure without incident. Estimated operating time was 15 minutes.
_________________________
Simon Williams, MD
Pulmonary/Thoracic Surgery
SW:
D:12/13/----
T:12/13/----