Patient Name: Putul Barua Hospital No. : 135799 Room No. : CCU-4 Date of Surgery: 01/08/2010 Admitting Physician: Joshua Steven Gatlin, MD Surgeon: Joshua Steven Gatlin, MD Preoperative Diagnosis: Recent onset hemoptysis. History of tuberculosis. Postoperative Diagnosis: No tuberculosis lesion seen. Procedure: Bronchoscopy indications. Mr. Barua requires bronchoscopy because of recent onset hemoptysis in a remote history of tuberculosis. PROCEURE: Patient was routinely pre-medicated with 25 mg of Demerol with 2 mg of Versed also use. About 4 CCs of 4% Xylocaine was used intraoperatively.
The glottis, epiglottis, pseudocords, and cords were normal. Upper trachea was normal. Lower trachea and carina were normal. There were a few small scattered clot spots present that were easily suctioned. The right upper lobe was observed, no endobronchial lesion was detected. The right lower lobe and right middle lobe were free of endobronchial lesion, the left side was centered. The left upper and lower lobe was investigated with no endobronchial lesions detected. We obtain no brushings because of patients INR in the fact that he became hypoxemic very quickly.
We had to do the procedure very quickly in discontinue it as soon as possible. No further significant hypoxemia was observed. (Continued) OPERATIVE REPORT Patient Name: Putul Barua Hospital No. : 153799 Date of Surgery: 01/08/2010 Page 2 The lowest level observed was about 86% which was immediately reversed with an increase in oxygen therapy. DIAGNOSIS: evidence of old hemorrhage. No new lesions seen. Recommend close follow up.