Patient Name: Patul Barua Patient ID. : 135799 Room No. : CCU 4 Date of Surgery: 01/08/—- Admitting Physician: Simon Williams, MD, Pulmonology Surgeon: Simon Williams, MD Preoperative Diagnosis: Recent onset hemoptysis, history of tuberculosis. Postoperative Diagnoses: No tuberculosis lesions seen. Surgical Procedures: Bronchoscopy. Specimen Removed: Blood clots. INDICATIONS: Mr. Barua requires bronchoscopy because of recent onset hemoptysis and a remote history of tuberculosis. PROCEDURE IN DETAIL: The 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 sectioned. 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 the patients 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. (Continued) OPERATIVE REPORT Patient Name: Putul Barua Patient ID. : 135799 Date of Surgery: 01/08/—- Page 2 The lowest level of hypoxia 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, MD Pulmonology SW:mf D:01/08/- – – – T:01/08/- – – –