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Bronchoscopy Medical Transcription Sample / Example Report

DATE OF PROCEDURE:  MM/DD/YYYY

PREPROCEDURE DIAGNOSIS:  Nodular infiltrates, rule out carcinoma, tuberculosis, fungal infection, allergic alveolitis or pneumonia.

POSTPROCEDURE DIAGNOSES:
1.  Nodular infiltrates, rule out carcinoma, tuberculosis, fungal infection, hypersensitivity pneumonitis or pneumonia.
2.  Leukoplakia of the vocal cords.

PROCEDURE:  Bronchoscopy.

PHYSICIAN:  John Doe, MD

PREMEDICATIONS:
1.  Demerol 50 mg.
2.  Phenergan 12.5 mg.
3.  Atropine 0.4 mg IM.
4.  Versed 0.5 mg IV.

ANESTHESIA:  Xylocaine 4% solution by updraft, cocaine 4% solution nasally, Xylocaine 2% solution through the bronchoscope.

SPECIMENS:  Bronchoalveolar lavage will be sent for Gram stain, culture and sensitivity, AFB smear, TB culture, direct and TB smear, fungal smears and culture, differential cell count and cytology.

PROCEDURE FINDINGS:
1.  Bilateral leukoplakia on the vocal cords.
2.  Diffuse tracheobronchitis.
3.  Patent segmental airways.
4.  Status post bronchoalveolar lavage, brushings and transbronchial biopsies from the right lower lobe with minimal bleeding.
5.  Touch preps of the specimens consistent with a necrotizing inflammatory process, but no malignancy or fungal element seen.

DESCRIPTION OF PROCEDURE:  The patient was premedicated with Demerol 50 mg, Phenergan 12.5 mg and atropine 0.4 mg IM. He received a treatment with Xylocaine 4% solution by updraft. His nasal mucosa was anesthetized with cocaine 4% solution applied by Q-tips. Additional 2% Xylocaine was given through the bronchoscope. The patient was breathing oxygen at 2 liters per minute by nasal prongs. He received additional Versed 0.5 mg IV for sedation. The Olympus fiberoptic bronchoscope was introduced transnasally into the posterior pharynx and vocal cords were visualized. There were bilateral whitish plaques on the cords consistent with leukoplakia. The cords otherwise moved well. The bronchoscope was then passed through the cords and the tracheobronchial tree was inspected. There was diffuse tracheobronchitis with slight viscous secretions noted. The segmental areas of the right upper lobe, right middle lobe, right lower lobe, left upper lobe, lingula and left lower lobe were patent with no fixed endobronchial obstructing lesions, active bleeding or mucous plugs.

The bronchoscope was then inserted into the right lower lobe and 20 mL aliquots of saline was lavaged into the right lower lobe with the return of nonpurulent and bloody solution. A brush was then passed though working channel of the bronchoscope and the brushings were taken from the periphery under fluoroscopic guidance. A biopsy forceps was then passed through the working channel of the bronchoscope, and under fluoroscopic guidance, transbronchial lung biopsies were taken from the various segments of the right lower lobe. There was minimal bleeding noted. Touch preps from the biopsies and also the brushings were consistent with a somewhat necrotizing inflammatory process, but no malignant cells or fungal elements were seen. After adequate clearing of secretions was accomplished, the bronchoscope was removed from the patient and the procedure was ended. The patient tolerated the procedure well and there were no complications. Post-bronchoscopy chest x-ray revealed good expansion without pneumothorax.