Case -AUDIT REPORT T9.2 OPERATIVE REPORT, BRONCHOSCOPY

Essay

Case
-AUDIT REPORT T9.2 OPERATIVE REPORT, BRONCHOSCOPY
LOCATION: Outpatient, Hospital
PATIENT: Kevin Hendrickson
PHYSICIAN: Gregory Dawson, MD
PREOPERATIVE DIAGNOSIS: Hemoptysis
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: The patient was intubated prior to the procedure. Informed consent was obtained from the patient's wife, who agreed to the procedure. The bronchoscope was passed with an endotracheal tube, 8.5 size. Then Lidocaine was utilized for lubrication for the endotracheal tube. Video monitoring was utilized through endoscopic technique. With the bronchoscope into the endotracheal tube, the left upper, lingula, and lower lobe regions for the subsegmental branches were visualized. They were cleaned with cold saline. There were no endobronchial lesions on the left side. Then the right upper lobe bronchus to segmental branches was visualized, and there were no endobronchial lesions or bleeding from any particular segment. Then the right mid-lobe branches up to medial and lateral branches up to segmental branches were visualized, and no bleeding was noted and no endobronchial lesions either. Then right lower lobe bronchus up to subsegmental branches was visualized, including the superior segmental bronchus. The anterior segment of the left lower lobe was showing evidence of active bleeding after washing with all the saline. After cold saline irrigation, the bleeding was able to be controlled. Then local epinephrine was also administered to cause local vasoconstriction. Specimens were collected to send for cytology to rule out malignancy and also to rule out any infectious etiology. The procedure was uneventful. Bleeding seemed to be controlled with cold saline irrigation administrations.
PATHOLOGY REPORT LATER INDICATED: Bronchial wash; no cytologic evidence of malignancy
T9.2:
SERVICE CODE(S): 31628__________________
ICD-10-CM DX CODE(S): R04.2_____________
INCORRECT/MISSING CODE(S): ________________________________________