EBUS Procedure Note [.phrase]

PULMONARY-CRITICAL CARE ATTENDING PROCEDURE NOTE

EBUS BRONCHOSCOPY PROCEDURE NOTE

PATIENT: @NAME@

MRN: @MRN@

DOB: @DOB@

DATE OF PROCEDURE: @TD@

PRE-OPERATIVE DIAGNOSIS: ***

POST-OPERATIVE DIAGNOSIS: Same

BRONCHOSCOPIST: ***

PROCEDURE(S) PERFORMED:

1. Flexible fiberoptic bronchoscopy, diagnostic

2. Endobronchial ultrasound lymph node survey

3. Endobronchial ultrasound guided fine needle aspiration of ***

ANESTHESIA TYPE: General

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. Endobronchial Ultrasound 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 *** 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. ***

I then proceeded to Lavage the *** with sterile saline, ***cc total, ***cc returned.

I then removed the standard bronchoscope and inserted an EBUS scope through endotracheal tube and into the distal trachea without difficulty:

An endobronchial ultrasound endoscope was utilized to examine the mediastinal and hilar lymph nodes (4 - 12 bilaterally) in order to assist with guiding the biopsy needle and evaluate lymph nodes. A complete examination of stations 4, 10, 11, 12, bilaterally and station 7 were performed. The following lymph nodes were found to be significant (> 5 mm): ***4R (lower paratracheal), ***10R (hilar), ***11R (interlobar), ***12R (lobar), ***7 (subcarinal), ***4L (lower paratracheal), ***10L (hilar), ***11L (interlobar) and ***12L (lobar)***.

Using a ***g Olympus TBNA needle, I then performed EBUS-guided TBNA of the station *** lymph node with ***x passes performed, provided fresh for pathology. It was reviewed on-site and was *** for lymphocytes and *** diagnostic of malignancy. These samples were also put into formalin containers for cell block. 

Using the same needle, I then performed EBUS-guided TBNA of the station *** lymph node with ***x passes performed, provided fresh for pathology. It was reviewed on-site and was *** for lymphocytes and *** diagnostic of malignancy. These samples were also put into formalin containers for cell block. 

SPECIMENS:

1. Station *** TBNA

COMPLICATIONS: {NONE APPARENT IP SH:114449}

ESTIMATED BLOOD LOSS: ***ml

SEDATION TIME: see anesthesia records. 

POST OPERATIVE CONDITION:

- stable, to holding for observation

- discharge home assuming patient stability in recovery. 

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

@TD@ @NOW@