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Manipulative Procedures Example 9

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Bronchoscopy Report

  • Hospital No.: 000027
  • Name: Sophie Carina
  • Service: ENT
  • Sex: Female
  • Age: 61
  • Race: White
  • Date of Operation: 10/01/91
  • Clinical Diagnosis: Esophageal Carcinoma
  • Procedure: Esophagoscopy and Bronchoscopy
  • Anesthetic: 4% Xyloc
  • Larynx: Normal, V/C OK
  • Pharynx: Normal

Trachea:

Extensive fungating encircling neoplastic-appearing tissue predom. On (L), invol. distal 1/4 of trach. down to and incl. Trach. @ level of carina. Carina massively widened and fixed but no ulcerative tissue noted. Orifices of both MSB markedly narrowed due to wide fixed carina. Both proximal MSB fiery red and prob. involved in some neoplastic process in distal trachea, esp. on left. Adequate view of both bronchial trees not possible.

Right Bronchus:

Left Bronchus:

Esophagus:

Esophagus normal down to 21 cm from the upper ant. alveolar ridge where circumferential necrotic hard mass with irregular eccentric lumen seen along with small tongue of edematous tissue post. and somewhat to (R). Scope would not pass through lesion, but Bx forceps were slipped by lesion 2.9 cm distal to edge of lesion.

  1. Bx carina & (L) trach. Wall
  2. Trach. wash.
  3. Bx esoph. Lesion

Diagnosis: Impression Carcinoma of the esoph with involv. of trachea

Remarks:

Endoscopist Morris de Bronchi, MD
Assistant Wright Hand, MD