Pulmonary Medical Transcription Operative / Surgical Sample Reports


Medical Transcription Pulmonary Operative Sample Report # 1:
 
DATE OF PROCEDURE: 

PREOPERATIVE DIAGNOSIS:  Subglottic tracheal stenosis.

POSTOPERATIVE DIAGNOSIS:  Subglottic tracheal stenosis.

PROCEDURE PERFORMED:  Fiberoptic bronchoscopy.

SURGEON:  John Doe, MD

ASSISTANT:  None.

INDICATIONS:  Subglottic stenosis.

Consent was obtained from the patient prior to procedure after explanation in lay terms the indications, details of procedure, and potential risks and alternatives.  The patient acknowledged and gave consent.

MEDICATIONS:  The patient received 50 mcg of fentanyl intravenous, Xylocaine spray to the throat and Xylocaine gel into the nostrils.  A total of 8 mg of Versed was given through the IV; however, her intravenous line had come out at some point early in the procedure and much of the medications did not get to the patient and a new IV line was started prior to initiating the procedure.

DESCRIPTION OF PROCEDURE:  The procedure was performed in the endoscopy suite.  The bronchoscope could not be passed easily through either nostril due to narrow nares and the patient's discomfort.  No obvious trauma was caused by trying to pass the scope.  A bite block was placed and the bronchoscope was inserted orally once sufficient sedation was obtained.  The vocal cords were visualized.  The patient appeared to have some right true vocal cord weakness.  The vocal cords did approximate in the midline.  Just below the vocal cords, in the subglottic area, there was scar tissue noted and some mild to moderate narrowing of the upper trachea with almost complete closure of the airway on exhalation.  Pictures were taken of the upper trachea, both on inhalation and exhalation.  Airways were otherwise quickly examined.  The trachea; carina; right upper, middle and lower lobe bronchi; left main stem bronchus and upper and lower lobe bronchi were patent without significant mucosal abnormalities.  Other than associated anxiety, the patient tolerated the procedure well maintaining good oxygen saturation during the procedure and was stable.  On conclusion, no specimens were collected.

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Medical Transcription Pulmonary Operative Sample Report # 2:
 
DATE OF PROCEDURE: 

PREOPERATIVE DIAGNOSIS:  Bilateral pulmonary infiltrates.

POSTOPERATIVE DIAGNOSES:

1.  Diffuse tracheobronchitis.
2.  Bilateral pneumonia.

PROCEDURE PERFORMED:  Fiberoptic bronchoscopy with transbronchial biopsy.

SURGEON:  John Doe, MD

ASSISTANT:  None.

CONSCIOUS SEDATION:

1.  Demerol 25 mg IV push.
2.  Versed 3 mg IV push.

ANESTHESIA:  Lidocaine 2% via intranasal instillation.

ANESTHESIOLOGIST:  Jane Doe, MD

SPECIMENS SENT:

1.  Bronchoalveolar lavage sent for cytology and acid-fast bacillus.
2.  Bronchial washings sent for fungal smear and culture, acid-fast bacillus smear and culture, Gram stain, C&S and DFA for Legionella.
3.  Bronchial brushings sent for cytology.
4.  Transbronchial biopsy sent for pathologic review.

FINDINGS:  Normal right nasal passage and posterior pharynx, vocal cords appeared to move normally during pronation and trachea was within normal limits.  Upon entering the level of the carina, there appeared to be mild diffuse tracheobronchitis extending throughout the right and left bronchial trees.  However, no endobronchial lesions or mucosal irregularities were appreciated.  Upon lavage of the right upper lobe, there was aspiration of some very scanty yellow purulent mucous plugs, but these cleared quite rapidly after the first administration of lavage.

DESCRIPTION OF PROCEDURE:  After appropriate consent was obtained from the patient, all risks and benefits were explained to him.  He was brought to the endoscopy suite and administered local anesthesia to the right naris and posterior pharynx.  This was then followed by administration of conscious sedation.  The patient was first administered Demerol 25 mg IV followed by titrating dose of IV Versed.  An adequate level of conscious sedation was achieved after administration of 3 mg of IV Versed.  At this point, an Olympus bronchofiberscope was inserted into the right naris, advanced to the posterior pharynx through the vocal cords and into the trachea.  Systematic inspection was then carried out of the entire tracheobronchial tree.  The bronchoscope was then advanced to the right upper lobe and the bronchoscope was wedged into the apical segment.  Bronchoalveolar lavage was then performed at this segment utilizing 60 mL of saline.  Bronchoscope was then pulled back at the level of the carina and advanced into the right middle lobe.  Under fluoroscopic guidance, bronchial brushings were obtained from the medial and lateral segments of the right middle lobe.  Bronchoscope was then pulled back and then advanced into the right lower lobe, and under fluoroscopic guidance, transbronchial biopsies x3 were obtained from various subsegments of both the right lower lobe and right middle lobe.  When this was completed, the additional bronchial washings were obtained from right lower lobe and right middle lobe.  The area was then inspected for any acute hemorrhage, but none were seen.  The bronchoscope was withdrawn.  The patient tolerated the procedure well.  There were no complications.
 
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Medical Transcription Pulmonary Operative Sample Report # 3
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DATE OF PROCEDURE: 
 
PREOPERATIVE DIAGNOSIS:  Left perihilar mass.
 
POSTOPERATIVE DIAGNOSES:  Left perihilar mass, mucosal abnormality in the posterior subsegment of the left upper lobe.
 
PROCEDURE PERFORMED:  Bronchoscopy, transbronchial lung biopsy and bronchial lung biopsy, brushing and washing.
 
SURGEON:  John Doe, MD
 
ASSISTANT:  None.
 
ANESTHESIA:  MAC.
 
DESCRIPTION OF PROCEDURE:  After the procedure was explained to the patient with the merits and the complications, he agreed and signed the consent.  After consent was obtained, with the patient in supine position, under monitored anesthesia care, the scope was introduced through the mouth and the larynx and the laryngeal area were inspected.  All of them were normal.  The scope was then inserted through the trachea into the carina, which was sharp and clear.  There was a moderate amount of thick-thin secretions that were suctioned through both right and left main bronchi.  The scope was then directed into the right main bronchus and then the right upper lobe bronchus with its subsegments were inspected.  All of them were normal.  Right middle lobe and right lower lobe bronchi with their subsegments were also inspected and were normal.  The scope was then directed into the left side, where the left main bronchus was normal.  Left lower lobe and middle lobe bronchus with their subsegments were normal.  The left upper lobe bronchus, anterosuperior segment showed anterior subsegment to have a bulging in one of its sub-bronchi.  Under fluoroscopy, biopsy forceps was inserted and several pieces of lung tissue were obtained from the area of the left perihilar lesion.  Then, brushing was done in the same area.  Washing was also done in the same area.  Then, in a separate container, several pieces of bronchial tissue were taken from the area that was bulging, anterosuperior subsegment of the left upper lobe bronchus.  All specimens were submitted for cytology, pathology and/or for culture.  The patient tolerated the procedure well with no apparent complications.  Chest x-ray is pending.

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Medical Transcription Pulmonary Operative Sample Report # 4:

BRONCHOSCOPY DICTATION SAMPLE REPORT

PROCEDURE PERFORMED:  Bronchoscopy.

DESCRIPTION OF PROCEDURE: The patient had been previously intubated and was on mechanical ventilatory support. He was on Diprivan and fentanyl drip for sedation, which was continued and adjusted during the procedure. He received treatment with Xylocaine 4% solution by updraft. His FiO2 was increased to 100% during the procedure. The Olympus fiberoptic bronchoscope was introduced through an endotracheal tube adaptor and the tip of the endotracheal tube was noted to be in good position above the carina. There was mucoid coating of the endotracheal tube noted. There was diffuse tracheobronchitis with mucosal edema, scattered secretions and dynamic airway compression, particularly in the lower lobes. There was blood-streaked secretion trailing from the right lower lobe and no active bleeding was seen. The segmental areas of the right upper lobe, right middle lobe, right lower lobe, left upper lobe, lingulae and left lower lobe were patent with no fixed endobronchial obstructing lesions. No active bleeding and no mucous plugging; however, there was a dynamic airway compression, particularly in the lower lobes. Saline was irrigated in the various dependent airways with some clearing of secretions, which was not purulent or bloody. The endotracheal tube was also cleared from the bulk of the secretions lining the tube with the bronchoscope scraping it off and suctioning it. 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.

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Medical Transcription Pulmonary Operative Sample Report # 5:


DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Right lower lobe nodule.
2.  Chronic obstructive pulmonary disease.
3.  Hypertension.
4.  History of tobacco use.
5.  Anxiety disorder.
6.  History of mild obesity.

POSTOPERATIVE DIAGNOSES:
1.  Right lower lobe nodule.
2.  Chronic obstructive pulmonary disease.
3.  Hypertension.
4.  History of tobacco use.
5.  Anxiety disorder.
6.  History of mild obesity.

PROCEDURES PERFORMED:
1.  Fiberoptic bronchoscopy.
2.  Right thoracotomy.
3.  Wedge resection, right lower lobe, x2.
4.  Wedge resection, right upper lobe.
5.  Biopsy of mediastinal lymph node.
6.  Biopsy of lymph node in sump of Borrie.
7.  Instillation of ON-Q pain management system.
 
SURGEON:  John Doe, MD

ANESTHESIA:  General. 

DESCRIPTION OF OPERATION:  The patient was brought to the operating room. After the induction of adequate general anesthesia, the patient was placed, prepped and draped in sterile fashion. Fiberoptic bronchoscopy with tracheobronchitis noted. A bronchial blocker was then placed. We placed the patient in the right posterolateral thoracotomy position and a general posterolateral thoracotomy incision was made through the various muscular layers. We then resected a short segment of posterior rib to control fracture and we controlled the neurovascular bundle with Ligaclips. Being satisfied with that, we opened the chest widely. We then inspected the upper lobe for any nodularity and there was only a small bit in the apex, which we forwarded to pathology for analysis. Furthermore, we then found small nodules in the lower lobe which were wedge excised and forwarded to pathology, which were also benign. We then found some lymph nodes in the hilum, which we forwarded to pathology for analysis and these were benign and we found about a 1.5 cm lymph node in the sump of Borrie, which was carefully dissected and excised and found to have granulomatous changes. Then, we obtained maximum hemostasis throughout the chest. Placed posterior/anterior chest tube brought through lateral stab incisions. We irrigated 1.5 liters of bacitracin solution and closed with doubled chromic suture followed by #0, 2-0 and 3-0 subcuticular stitch. Also the ON-Q catheter was laid in the deep tissues, brought through a lateral stab wound incision. The patient tolerated the procedure well and was taken to the recovery room in satisfactory condition. Sponges and needles counts correct x2.

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Medical Transcription Pulmonary Operative Sample Report # 6:

DATE OF OPERATION: 
 
PREOPERATIVE DIAGNOSIS:  Left lung mass, very suspicious for primary lung cancer.
 
POSTOPERATIVE DIAGNOSIS:  Left lung mass, very suspicious for primary lung cancer.
 
OPERATIONS PERFORMED:
1.  Fiberoptic bronchoscopy with bronchioalveolar lavage.
2.  Exploratory left thoracotomy.
3.  Left lower lobe wedge resection.
4.  Left pneumonectomy.
 
SURGEON:  John Doe, MD
 
ASSISTANT:  Joseph Doe, MD
 
ANESTHESIA:  General endotracheal
 
ANESTHESIOLOGIST:  Jane Doe, MD
 
COMPLICATIONS:  None.
 
CONDITION:  Stable to CVICU.
 
CHEST TUBES:  One straight #32-French pleural tube to water seal.
 
FINDINGS:  Fiberoptic bronchoscopy was within normal limits.  There were no intrinsic endobronchial lesions or external compression on the bronchus.  On exploratory left thoracotomy, there was a 5 x 6 left hilar mass.  A biopsy of the mass from the left lower lobe was performed and sent off.  This wedge resection was returned from pathology as a squamous cell carcinoma by frozen resection.  Therefore, left pneumonectomy was indicated.
 
DESCRIPTION OF OPERATION:  The patient was taken to the operating room, placed on the table in supine position and placed under adequate general anesthesia.  She was then intubated with a double-lumen endotracheal tube.  Fiberoptic bronchoscopy was performed through the endotracheal tube without complications with the findings as noted above.  The scope was removed. 
 
The patient was then turned to the right lateral decubitus position and prepped and draped in normal sterile fashion on the posterolateral chest wall.  A posterolateral thoracotomy incision was made.  The latissimus muscle was divided.  The chest was entered through the left 5th interspace.  The dissection was carried down to the pulmonary arteries and veins, each of these were dissected out.  The inferior pulmonary ligament was released and this enabled us to free the lung up to do a small wedge resection in the lower lobe.  This was sent off to pathology for permanent section, returned as a squamous cell carcinoma.
 
Therefore, we proceeded with complete dissection of the left pulmonary artery and left superior and left inferior pulmonary veins; they were each dissected out.  They were ligated with TA30 vascular stapling devices and then each was transected.  This left us simply with the left main stem bronchus; this was dissected out and the peribronchial lymph nodes were removed with the specimen.  The left main stem bronchus was clamped just below the carina.  The patient was still ventilating easily through the right lung. 
 
Therefore, the left main stem bronchus was transected and the specimen was removed to be sent off to pathology for permanent section including bronchial margins.  On gross inspection, the bronchial margins were indeed clear.  The area was then irrigated with antibiotic saline solution.  A single chest tube was inserted through a separate stab wound and sewn to the skin.  This was connected to water seal. 
The chest was then closed appropriately.  Wounds dressed in a sterile manner.  Instrument counts and sponge counts were correct at the end of the procedure.  The patient tolerated that well and was sent to the CV ICU in very stable condition.



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