Case 3 Operative Report

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HILLCREST MEDICAL CENTER

OPERATIVE REPORT

Patient Name: Putul Barua

Hospital No.: 135799

Room No.: CCU-4

Date of Admission: 01/07/2010

Date of Surgery: Jan 8 2010

Admitting Surgeon: Dr. Joshua Stephen Gatlin, MD

Surgeon: Dr. Joshua Stephen Gatlin, MD

Diagnosis: Evidence of old hemorrhage. No new lesions seen. Recommend close follow-up.

Indications: Mr. Barua requires bronchoscopy because of recent onset hemoptysis in a remote history of tuberculosis.

Preoperative Diagnosis: Recent onset hemoptysis, history of tuberculosis

Postoperative Diagnosis: No tuberculosis lesions seen

Operative Procedures: Bronchoscopy

PROCEDURE IN DETAIL: Patient was routinely premedicated with 25 milligrams of Demerol, with 2 marograms Versed also used. About 4 ccs of four percent Xylocaine was used intraoperatively. The glottis, epiglottis, pseudocords and cords were normal. Upper trachea was normal. Lower trachea and carina were normal. There were a few small scattered clot spots present that were easily suctioned. The right upper lobe was observed. No endobronchial lesion was detected. The right lower lobe and right middle lobe were free of endobronchial lesion. The left side was entered. The left upper and lower lobe was investigated with no endobronchial lesions detected. We obtained no brushings because of patient's INR and the fact that he became hypoxemic very quickly. We had to do the procedure very quickly and discontinue it as soon as possible. No further significant hypoxemia was observed. The lowest level observed was about 86 percent, which was immediately reversed with an increase in oxygen therapy.

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Dr. Joshua Stephen Gatlin, MD

JG:pw
D:01/10/2010
T: 01/08/2010
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