Thoracentesis Procedure Note [.phrase]

PROCEDURE NOTE: THORACENTESIS, ***

Date: @TD@ Time: ***

Indication: {indications:60229}.

Consent: {consent:60185}

Usual sterile technique was used throughout the procedure. Following identification of procedure site by {landmarks:60239}, the area was prepped with {prep:60203}. The area was anesthetized with ***ml of 1% xylocaine. Patient was also given IV {Fentanyl Midazolam Ketamine Morphine Sulfate:110620} for the procedure. Using usual technique, a {gauge:60251} gauge {device:60231} was slowly advanced while aspirating. ***ml of {drainage:60232} fluid was obtained. Vacuum canisters were {used:60233}. A dressing was placed. {Pt tolerated procedure:60227::"No complications","patient tolerated well."}.

A chest xray was ordered to evaluate for pneumothorax.

Total Fluid Removed: ***ml

Color of Fluid: ***

Sent for: Cell Count Gram Stain Cultures LDH Glucose pH Cytology

Christian Castaneda, MD

Pulmonary Critical Care Medicine

Queens Medical Center Punchbowl/West O'ahu

@TD@