Case 3 Operative
OPERATIVE REPORT
Patient Name: Putul Barua
Patient ID: 135799 DOB: N/A Age: 42 Sex: M
Room No: CCU4
Date of Admission: 01/07
Date of Procedure: 01/08
Admitting Physician: Simon Williams, M.D. (Pulmonology)
Surgeon: Simon Williams, M.D. (Pulmonology)
Assistant: N/A
Preoperative Diagnosis: Recent-onset hemoptysis, history of tuberculosis.
Postoperative Diagnosis: No tuberculosis lesions seen.
Operative Procedure: Bronchoscopy
Specimen Removed: Blood clots.
IV Fluids: N/A
Estimated Blood Loss: N/A
Urine Output: N/A
Complications: N/A
INDICATIONS: Mr. Barua requires bronchoscopy because of recent-onset hemoptysis and a remote history of tuberculosis.
PROCEDURE Patient was routinely premedicated with 25 mg of Demerol with 2 mg of Versed also used. About 4 mL of 4% Xylocaine was used during the procedure. The glottis, epiglottis, pseudocords, and cords were normal. Upper trachea was normal. Lower trachea and carina 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 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 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
OPERATIVE REPORT
Patient Name: Putul Barua
Patient ID: 135799
Date of Procedure: 01/08
Page 2
observed was about 86%, which was immediately reversed with an increase in oxygen therapy.
DIAGNOSIS: Evidence of old hemorrhage. No new lesions seen. Recommend close follow-up.
_________________________
Simon Williams, M.D.
Pulmonology
SW:CMD
D:12/9/14
T:12/9/14
Patient Name: Putul Barua
Patient ID: 135799 DOB: N/A Age: 42 Sex: M
Room No: CCU4
Date of Admission: 01/07
Date of Procedure: 01/08
Admitting Physician: Simon Williams, M.D. (Pulmonology)
Surgeon: Simon Williams, M.D. (Pulmonology)
Assistant: N/A
Preoperative Diagnosis: Recent-onset hemoptysis, history of tuberculosis.
Postoperative Diagnosis: No tuberculosis lesions seen.
Operative Procedure: Bronchoscopy
Specimen Removed: Blood clots.
IV Fluids: N/A
Estimated Blood Loss: N/A
Urine Output: N/A
Complications: N/A
INDICATIONS: Mr. Barua requires bronchoscopy because of recent-onset hemoptysis and a remote history of tuberculosis.
PROCEDURE Patient was routinely premedicated with 25 mg of Demerol with 2 mg of Versed also used. About 4 mL of 4% Xylocaine was used during the procedure. The glottis, epiglottis, pseudocords, and cords were normal. Upper trachea was normal. Lower trachea and carina 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 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 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
OPERATIVE REPORT
Patient Name: Putul Barua
Patient ID: 135799
Date of Procedure: 01/08
Page 2
observed was about 86%, which was immediately reversed with an increase in oxygen therapy.
DIAGNOSIS: Evidence of old hemorrhage. No new lesions seen. Recommend close follow-up.
_________________________
Simon Williams, M.D.
Pulmonology
SW:CMD
D:12/9/14
T:12/9/14