Over 500 Medical Transcription Sample Reports For Medical Transcriptionists!!

Direct Laryngoscopy Flexible Bronchoscopy Sample Report


SURGEON:  John Doe, MD

DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed in supine position on the operating table. General anesthesia was induced and the patient was ventilated through an already intact tracheostomy tube.

Anterior commissure laryngoscope was first utilized. The patient was found to have a large amount of redundant soft tissue but no discrete mass or lesion in the oropharynx or hypopharynx. The large amount of soft tissue included lingual tonsillar hypertrophy, a large amount of postcricoid edema consistent with gastroesophageal reflux disease. True vocal folds showed a mild to moderate amount of Reinke's edema. There was a small amount of resolving ecchymosis along the posterior aspect of the right true vocal fold at the vocal process. No other significant trauma visible to the larynx.

Next, the bronchoscope was passed through the patient's oral cavity and through the true vocal folds. The immediate subglottis was visualized along with the entrance of the tracheostomy tube, which was seen to be well positioned within the trachea. There was no visible fixed obstruction at this level. At this point, the #6 extended length Shiley was removed and a #5 uncuffed extended length Shiley was placed into the already intact tracheotomy. Under visualization with the bronchoscope, it was seen to extend well into the trachea with good positioning. The bronchoscope and laryngoscope were then removed.

The bronchoscope was then placed through the tracheostomy tube and the trachea was visualized down to the larynx. There seemed to be no tracheomalacia and no masses or lesions down to the level of the carina. The new tracheostomy tube was then secured to the patient's neck and the patient was then awakened and taken to the postanesthesia care unit in stable condition.