Dictated by Dr Joshua Stephen Gaitlin M.D

  1. I. IDENTIFYING INFORMATION

Patient Name

Batool Barua

Hospital Number

135799

Room Number

CCU 4

Date of Operation

08/01/2010

Admitting Physician

Dr. Joshua Stephen Gaitlin M.D

  1. II. PRE-OPERATIVE DIAGNOSIS

Recent onset hemoptysis, history of tuberculosis

  1. III. POST-OPERATIVE DIAGNOSIS

No tuberculosis lesion seen

  1. IV. PROCEDURE PERFORMED

Bronchoscopy

  1. V. SURGEON

Dr. Joshua Stephen Gaitlin M.D

  1. VI. INDICATIONS FOR SURGERY

Mr. Barua requires bronchoscopy because of recent onset hemoptysis and a remote history of tuberculosis.

  1. VII. PROCEDURE

Patient was routinely pre-medicated with 35 mg of Demerol with 2 mg of Verstat also used about 4 cc’s of 4 % Xylocaine was used intra-operatively. The glottis, epiglottis, single chords and coolants 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 endo bronchial lesion was detected. The right lower lobe and right middle lobe were free of endo bronchial lesion. The left side was centered; the left upper and lower lobe was investigated with no endo bronchial lesions detected. We obtained no brushings because of patient 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%, which was immediately reversed with an increase in oxygen therapy.

  1. VIII. DIAGNOSIS

Evidence of old hemorrhage; no new lesions seen,

  1. IX. RECOMMENDATION

Close follow up

END OF OPERATIVE REPORT

Physician’s Name M.D

Date of Dictation

08/01/2010

Date of transcription

31/03/2010

This is just a sample term paper for marketing purposes. If you want to order term papers, essays, research papers, dissertations, case study, book reports, reviews etc. Please access the order form.