Sample Type / Medical Specialty: Cardiovascular / Pulmonary Description: Bronchoscopy for hypoxia and increasing pulmonary secretions
Sample Name: Bronchoscopy - 6
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Hypoxia and increasing pulmonary secretions.
POSTOPERATIVE DIAGNOSIS: Hypoxia and increasing pulmonary secretions.
ANESTHESIA: Moderate bedside sedation.
FINDINGS: Abundant amount of clear thick secretions throughout the main airways.
INDICATIONS: The patient is a 43-year-old gentleman who has been in the ICU for several days following resection of small bowel for sequelae of SMV occlusion. This morning, the patient developed worsening hypoxia with abundant sputum production requiring frequent suctioning from his ET tube. The patient also had new-appearing atelectasis versus infiltrates in the right lower lobe of his lung on chest x-ray. Given these findings, it was felt that bronchoscopy could further define source of secretions and send more appropriate specimen for culture if need be.
OPERATION: The patient was given additional fentanyl, Versed as well as paralytics for the procedure. Small bronchoscope was inserted through the ET tube and to the trachea to the level of carina. There was noted to be thick clear secretions adherent to the trachea walls as well as into the right mainstem bronchus. Extensive secretions extended down into the secondary airways. This was lavaged with saline and suctioned dry. There is no overt specific occlusion of airways, nor was there any purulent-appearing sputum. The bronchoscope was then advanced into the left mainstem bronchus, and there was noted to be a small amount of similar-appearing secretions which was likewise suctioned and cleaned. The bronchoscope was removed, and the patient was increased to PEEP of 10 on the ventilator. Please note that prior to starting bronchoscopy, he was pre oxygenated with 100% O2. The patient tolerated the procedure well and lavage specimen was sent for gram stain as well as routine culture.
cardiovascular / pulmonary, pulmonary secretions, bronchoscopy, hypoxia, peep, smv occlusion, atelectasis, bedside sedation, bronchoscope, chest x-ray, mainstem, right lower lobe, mainstem bronchus,
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.