Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Bronchoalveolar lavage.

Description: Evaluation of airway for possible bacterial infection performed using bronchoalveolar lavage.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Fever.

POSTOPERATIVE DIAGNOSIS: Fever.

PROCEDURES: Bronchoalveolar lavage.

INDICATIONS FOR PROCEDURE: The patient is a 28-year-old male, status post abdominal trauma, splenic laceration, and splenectomy performed at the outside hospital, who was admitted to the Trauma Intensive Care Unit on the evening of August 4, 2008. Greater than 24 hours postoperative, the patient began to run a fever in excess of 102. Therefore, evaluation of his airway for possible bacterial infection was performed using bronchoalveolar lavage.

DESCRIPTION OF PROCEDURE: The patient was preoxygenated with 100% FIO2 for approximately 5 to 10 minutes prior to the procedure. The correct patient and procedure was identified by time out by all members of the team. The patient was prepped and draped in a sterile fashion and sterile technique was used to connect the BAL lavage catheter to Lukens trap suction. A catheter was introduced into the endotracheal tube through a T connector and five successive 20 mL aliquots of normal saline were flushed through the catheter, each time suctioning out the sample into the Lukens trap. A total volume of 30 to 40 mL was collected in the trap and sent to the lab for quantitative bacteriology. The patient tolerated the procedure well and had no episodes of desaturation, apnea, or cardiac arrhythmia. A postoperative chest x-ray was obtained.

Keywords: cardiovascular / pulmonary, abdominal trauma, bal lavage, lukens trap suction, splenectomy, splenic laceration, bronchoalveolar lavage, fever, catheter, bronchoalveolar, lavage, airway,
NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports. These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the preference of the dictating physician. All names and dates have been changed (or removed) to keep confidentiality. Any resemblance of any type of name or date or place or anything else to real world is purely incidental.
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Transcribed Medical Transcription Sample Reports and Examples