Manipulative Procedures Example 10

View the suggested abstraction.

Bronchoscopy Report

  • Hospital No.: 000028
  • Name: Essie Phagus
  • Service: ENT
  • Sex: Female
  • Age: 49
  • Race: Black
  • Date of Operation: 5/5/91
  • Clinical Diagnosis: Carcinoma of the lung
  • Procedure: Bronchoscopy
  • Anesthetic: General
  • Larynx: Vocal cords move normally
  • Pharynx: WNL
  • Trachea: Normal, Carina also normal

Right Bronchus:

(R) main stem bronchus partially occluded by mucus & heaped up friable tissue. RUL bronchus completely occluded with granular tissue. Right bronchus intermedius almost completely occluded with mucus and tissue.

Left Bronchus:

WNL except for slightly reddened mucosa in left main stem bronchus.



Bronchogenic carcinoma: tumor involving RUL and right bronchus intermedius.


Fiberoptic bronchoscopy performed via transnasal approach. RUL bronchus - Bx taken x 3.

Endoscopist S.C.Opes, MD
Assistant I.C. Tou, MD