2. Susan Oster, 45, is admitted to the hospital with a temperature of 38.5º C, heart rate 102 beats/min, respiration 20/min with septicemia and SIRS. WBC 12,500. Documentation states respiratory and acute hepatic failure are due to septicemia.
3. OPERATIVE REPORT
PATIENT: Mara Bell Lee
PHYSICIAN: Randy Greenfield,
MD PREOPERATIVE DIAGNOSIS: Pleural effusion with unknown cause.
POSTOPERATIVE DIAGNOSIS: Pleural effusion with unknown cause.
Four-quadrant pleural biopsy,
Pleural drainage with small catheter temporary chest tube.
PROCEDURE: With the usual Betadine scrub to the area marked by ultrasound, the area was anesthetized with approximately 15 cc of 1% lidocaine, and then a small-caliber #21-gauge needle was inserted into the space. Fluid was removed for appropriate bacteriological, hematological, and chemical analyses.Once this was accomplished, then a larger tube using a Cope pleural biopsy needle was inserted into the space, and four quadrants were biopsied and sent for appropriate pathological specimens. Once that was accomplished, then using a small-caliber temporary chest tube from the Cope, as well as the pneumothorax set, the space was entered, and 1.5 liters of bloody fluid was removed. A small bandage was attached afterward. There was no pain involved, and the chest x-ray will be taken afterward to assure ourselves that we had a reasonable effect without any ill consequences.
PATHOLOGY REPORT PATIENT: MaraBell Lee
PHYSICIAN:Randy Greenfield, MD CLINICAL HISTORY: Pleural effusion.GROSS DESCRIPTION: 1650 ml bloody fluid received in two glass Vacutainers.SPECIMEN RECEIVED: Pleural fluid.SPECIMEN ADEQUACY: Specimen satisfactory for cytologic evaluation.DIAGNOSIS: No cytologic evidence of... [continues]
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