PREOPERATIVE DIAGNOSES: Persistent hemoptysis and pneumonia and changes on x-ray. POSTOPERATIVE DIAGNOSES: Same. PROCEDURE: Transbronchial biopsy, bronchial biopsy, bronchoalveolar lavage, bronchial washings, and bronchial brushings. PHYSICIAN: Hurada Maltose, MD FINDINGS: The patient was sedated and prepped while he was on the ventilator (status, ventilator dependent is reported with a V code), which did not really require much additional drug at all. Please see the drug sheet for further information. PROCEDURE: The patient was monitored throughout the procedure with usual monitoring. There were no significant changes in blood pressure, oxygen saturation, or pulse rate, nor did any arrhythmias develop. No pneumothorax was discovered post procedure by chest x-ray or by auscultation. Once the patient was sedated, more than usual since he was maintained on a ventilator in the first place, the bronchoscope was introduced with a #9 endotracheal tube so it fit quite easily, and we were able to see the distal 2 centimeters of trachea, which was red and swollen, and the carina, which was red and swollen, and all the airways were red and swollen and with white plaquing consistent with candidiasis on the left mainstem and going down toward the lower lobe. The area in question was biopsied, brushed, and washed and subjected to bronchioalveolar lavage, as well as bronchial brushings with sheath and nonsheath brushes, as well as bronchial biopsies and transbronchial biopsies performed in that area. There were no complications. There was some blood seen in the left lower lobe, which was where most of the secretions were, and they were bloody. There were excess secretions everywhere but most were in the left lower lobe. The specimens were sent for appropriate pathological, cytological, and bacteriological studies, including a tissue sample, which was sent for bacteriological studies. Follow-up will be done in the Intensive Care Unit when we get the information back from the Lab. Procedure Key Terms: bronchoscopy, lung biopsy, bronchoalveolar lavage ICD-10-CM Key Terms: hemoptysis, pneumonia CPT Modifiers ICD-10cm.

1. PREOPERATIVE DIAGNOSES: Persistent hemoptysis and pneumonia and changes on x-ray.
POSTOPERATIVE DIAGNOSES: Same. PROCEDURE: Transbronchial biopsy, bronchial
biopsy, bronchoalveolar lavage, bronchial washings, and bronchial brushings. PHYSICIAN:
Hurada Maltose, MD FINDINGS: The patient was sedated and prepped while he was on the
ventilator (status, ventilator dependent is reported with a V code), which did not really require
much additional drug at all. Please see the drug sheet for further information. PROCEDURE:
The patient was monitored throughout the procedure with usual monitoring. There were no
significant changes in blood pressure, oxygen saturation, or pulse rate, nor did any arrhythmias
develop. No pneumothorax was discovered post procedure by chest x-ray or by auscultation.
Once the patient was sedated, more than usual since he was maintained on a ventilator in the first
place, the bronchoscope was introduced with a #9 endotracheal tube so it fit quite easily, and we
were able to see the distal 2 centimeters of trachea, which was red and swollen, and the carina,
which was red and swollen, and all the airways were red and swollen and with white plaquing
consistent with candidiasis on the left mainstem and going down toward the lower lobe. The area
in question was biopsied, brushed, and washed and subjected to bronchioalveolar lavage, as well
as bronchial brushings with sheath and nonsheath brushes, as well as bronchial biopsies and
transbronchial biopsies performed in that area. There were no complications. There was some
blood seen in the left lower lobe, which was where most of the secretions were, and they were
bloody. There were excess secretions everywhere but most were in the left lower lobe. The
specimens were sent for appropriate pathological, cytological, and bacteriological studies,
including a tissue sample, which was sent for bacteriological studies. Follow-up will be done in
the Intensive Care Unit when we get the information back from the Lab. Procedure Key Terms:
bronchoscopy, lung biopsy, bronchoalveolar lavage ICD-10-CM Key Terms: hemoptysis,
pneumonia CPT Modifiers ICD-10cm