Hillcrest Medical Case 3 Operative

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OPERATIVE REPORT
Patient Name: Putul Barua
Patient ID: 135799Room: CCU4
Date of Surgery: 01/08/2013
Admitting Physician: Dr. Simon Williams, MD Pulmonology
Surgeon: Dr. Simon Williams, MD Pulmonology
Preoperative Diagnosis: Recent onset hemoptysis, history of tuberculosis. Postoperative Diagnosis: No tuberculosis lesions seen.
Operative Procedure: Bronchoscopy.
Specimens Removed: Blood clots.
Indications: Patient requires bronchoscopy because of recent onset hemoptysis and a remote history of tuberculosis. PROCEDURE: Patient was routinely pre-medicated with 25mg of Demerol with 2mg of Versed also used. About 4 milliliters of 4% Xylocaine was used during the procedure. The glottis, epiglottis, pseudocords, and cords were normal.  Upper trachea was normal. Lower trachea and carena were normal. A few small, scattered thrombi present were easily suctioned. The right upper lobe was observed. No endobronchial lesion was detected. The right lower lobe and the right middle lobe were free of endobronchial lesions. The left side was entered. The left upper and lower lobe was investigated with no endobronchial lesions detected. We obtained no brushings because of the patient’s INR and the fact that he became hypoxic very quickly. We had to do the procedure very quickly and discontinue it as soon as possible. No further significant hypoxia was observed. The lowest level of hypoxia observed was about 86%, which was immediately reversed with an increase in oxygen therapy.

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OPERATIVE REPORT
Patient Name: Putul Barua
Patient ID: 135799Room: CCU4
Date of Surgery: 01/08/2013
Page 2

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

______________________________________
Dr. Simon Williams, MD Pulmonology

SW/XX
D: 1/8/2012
T: 1/8/2013
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