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,