Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Surgery
Sample Name: Bronchoscopy - 7

Description: Diagnostic fiberoptic bronchoscopy.
(Medical Transcription Sample Report)

PROCEDURE: Diagnostic fiberoptic bronchoscopy.

ANESTHESIA: Plain lidocaine 2% was given intrabronchially for local anesthesia.

PREOPERATIVE MEDICATIONS:
1. Lortab (10 mg) plus Phenergan (25 mg), p.o. 1 hour before the procedure.
2. Versed a total of 5 mg given IV push during the procedure.

INDICATIONS: Right upper lobe lung mass, posterior segment.

Consent obtained from the patient's daughter.

PROCEDURE IN DETAIL: After appropriate sedation was achieved, the bronchoscope was introduced via the right nares and advanced to the upper larynx. Plain lidocaine 2% was used to anesthetize the laryngeal structures. After adequate anesthesia was achieved, close inspection of the laryngeal structures could be performed. Both vocal cords moved appropriately. Under direct visualization, the bronchoscope was advanced past the vocal cords and into the distal trachea. Additional 2% plain lidocaine was used in the trachea and the main stem bronchi for anesthesia. After adequate anesthesia was achieved, close inspection of the airways could be undertaken. The left tracheobronchial tree was inspected closely to the level of the subsegmental bronchi. All bronchi are patent with no endobronchial lesions and no mucosal lesions noted. The right tracheobronchial tree was also patent and intact with the mucosa normal. The bronchoscope was then introduced to the right upper lobe specifically to the posterior segment and washings/brushings and transbronchial lung biopsies were taken from that area. He had quite a bit of coughing during the diagnostic procedures despite lidocaine administration. A total of 5 mg of Versed was used to effect sedation. At one point, the bronchoscope had to be completely withdrawn so that the sample could be appropriately retrieved. Upon reintroduction, there was quite a bit of bleeding in his right nares. The right naris was packed for control of the bleeding. The procedure was completed and all samples were submitted for appropriate studies. A post procedure chest x-ray has been obtained and is still pending. He tolerated the procedure very well other then for the brisk epistaxis from the right nares. Packing to the right nares has been completed.


Keywords: surgery, fiberoptic, intrabronchially, larynx, distal trachea, diagnostic fiberoptic bronchoscopy, bronchoscopy, bronchoscope,
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Transcribed Medical Transcription Sample Reports and Examples