Detailed Bronchoscopy Procedure Note [.phrase]

PULMONARY-CRITICAL CARE ATTENDING PROCEDURE NOTE

BRONCHOSCOPY PROCEDURE NOTE

PATIENT: @NAME@

MRN: @MRN@

DOB: @DOB@

DATE OF PROCEDURE: @TD@

PRE-OPERATIVE DIAGNOSIS: ***

POST-OPERATIVE DIAGNOSIS: ***

BRONCHOSCOPIST: ***

PROCEDURE(S) PERFORMED:

1. Flexible fiberoptic bronchoscopy, diagnostic

2. Fiberoptic bronchoscopy with therapeutic aspiration of the Tracheobronchial Tree

ANESTHESIA TYPE: {ANESTHESIA IP SH:112817}

DESCRIPTION OF PROCEDURE:

After informed consent was obtained, the patient was taken to the Endoscopy/Bronchoscopy Suite, identified as @NAME@ and the procedure verified as Flexible Fiberoptic Bronchoscopy. A Time Out was held and the above information confirmed.

After adequate anesthesia was provided, the airway was secured by anesthesia with a size 7.5*** ETT.

After adequate topical anesthesia and intravenous sedation were provided,a standard flexible fiberoptic bronchoscope was passed through {:125346::"an endotracheal tube into the trachea without difficulty and an inspection of the airways revealed:","a bite block into the posterior pharynx. The vocal cords and epiglottis were visualized and were normal in appearance with the vocal cords adducting to midline symmetrically. The scope was then passed into the trachea without difficulty and an inspection of the airways revealed:"}

ENDOBRONCHIAL FINDINGS:

Inspection of the Left Lung was without evidence of mass, anatomic distortions, or hemorrhage.

Inspection of the Right Lung was without evidence of mass, anatomic distortions, or hemorrhage. 

Lavage of the *** was sent for micro and cytology. 

Secretions cleared and the standard bronchoscope was withdrawn.

The patient tolerated the procedure well.

SPECIMENS:

- *** BAL 

COMPLICATIONS: {NONE APPARENT IP SH:114449}

ESTIMATED BLOOD LOSS: ***ml

SEDATION TIME: see anesthesia records. 

POST OPERATIVE CONDITION:

- stable, to holding for observation

I will attempt to arrange followup for *** in ~1-2 weeks, with my colleagues, Drs. *** in clinic to discuss biopsy results.

This procedure was performed by myself independently of the time included in today's admission/progress note.

@ME@, MD

Pulmonary and Critical Care Medicine Attending

@TD@ @NOW@