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 & Bronchoalveolar Lavage

Description: Bronchoscopy with bronchoalveolar lavage. Refractory pneumonitis. A 69-year-old man status post trauma, slightly prolonged respiratory failure status post tracheostomy, requires another bronchoscopy for further evaluation of refractory pneumonitis.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Refractory pneumonitis.

POSTOPERATIVE DIAGNOSIS: Refractory pneumonitis.

PROCEDURE PERFORMED: Bronchoscopy with bronchoalveolar lavage.

ANESTHESIA: 5 mg of Versed.

INDICATIONS: A 69-year-old man status post trauma, slightly prolonged respiratory failure status post tracheostomy, requires another bronchoscopy for further evaluation of refractory pneumonitis.

PROCEDURE: The patient was sedated with 5 mg of Versed that was placed on the endotracheal tube. Bronchoscope was advanced. Both right and left mainstem bronchioles and secondary and tertiary bronchioles were cannulated sequentially, lavaged out. Relatively few tenacious secretions were noted. These were lavaged out. Specimen collected for culture. No obvious other abnormalities were noted. The patient tolerated the procedure well without complication.

Keywords: surgery, respiratory failure, bronchoalveolar lavage, refractory pneumonitis, tracheostomy, bronchoalveolar, bronchoscopy, pneumonitis,
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