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The patient was in the ICU on the ventilator, intubated, and so we simply used ICU sedation. We put the bronchoscope down the endotracheal tube. We could see the trachea, which appeared okay. The carina appeared normal. In the right and left lungs, all segments were patent and entered, and in the right lower lobe and middle lower lobe, there were increased, thick, tenacious secretions. No definite mucous plug. It did take a little suctioning to dislodge all of the mucus; however, it was not as bad as I thought it would be looking at the x-ray. The area was brushed, washed, and then, to be more specific, because of evidence on chest x-ray of something going on in the periphery/ a bronchoalveolar lavage of the right lower lobe is performed. The patient tolerated the procedure well. Specimens were performed. Specimens were sent for appropriate cytological, pathological, and bacteriological studies, and we hope to be able to follow up on that tomorrow.

PATHOLOGY REPORT LATER INDICATED: See Report 66.

PREOPERATM DIAGNOSIS: Chronic adenotonsillitis and chronic tonsillitis.

POSTOPERATM DIAGNOSIS: Chronic adenotonsillitis and chronic tonsillitis.

PROCEDURE PERFORMED: Tonsillectomy and adenoidectomy.

OPERATM NOTE: The patient is a 1S-year-old woman who was seen in the offlce and diagnosed with the above condition. Decision was made in consultation with the patient to undergo the procedure.

She was admitted through the same-day department and taken to the operating room, where she was administered general anesthetic by

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APPENDIX A I RCPOTTS

intravenous injection. She was then intubated endotracheally' The Jennings

gug *r, inserted into the mouth and expanded; this was secured to a Mayo stand. TWo red rubUer catheters were pliced through the nose and

brought

outthroughthemouth;theseweresecuredwithsnaps'Thiswasdoneto etevate th[ palate. A lar,rgeal mirror was placed in the nasopharynx' The

adenoid tissue was visuiliied. Using suction cautery, the adenoid tissue was

removed in systemic fashion. oncJthis was completed, the- red rubbers were

i"f"ur.a and |rought out through the nose. fhe iight tonsilwas grasped - with an Allis forceps and retracied mediatly using a harmonic scalpel, and

thecapsulewasenteredbilaterally.Thetonsilwasremovedfromitsfossain an inferior fashion, and one ,-uil ut"u was cauterized. The left tonsil was lfr"., grurp"d with u.r atnt forceps and retracted medially. Again, the capsule

was identifled laterally, and the.harmonic scalpel was used to remove the

tonsil from its fossa in an inferior to superior fashion' Once this was

.o*praraa, the bed was inspected, and -two

small areas wele cauterized here'

Three tonsillar sponges weie soaked in 1o/o Marcaine with epinephrine; one

was placed in the ,rulropt ury.r, and one in each tonsil bed. These were left

in p6sition for 5 minuier, u.td at the end of this interval they were remcved'

The beds were inspected. No further bleeding was noted. The gag was then

removedfromthemouth.TheTMJjointwaschecked.Thepatientwas allowed to recover from a general anesthetic and taken to the post

anesthesia care unit in stadle condition. There were no complications during this Procedure'

PATIIOLOGY RBPORT LATER INDICATED: Benign tonsil and adenoid

tissue.

PRE0PERATIVE DIAGN0SIS: Pleural fluid, unknown cause.

PoSToPE,RATIVEDIAGNOSIS:Loculatedpleuraleffusionwithremoval of 40 cc of bloodY Pleural fluid.

PROCEDURE PERFORMED: Diagnostic thoracentesis'- -o, ultrasound, the areas were lolulated by that method as well as by

attempting to draw out fluid. I had to do four different sticks to get 40 cc

of fluid and that was about the extent of each pocket' T,here were four

&i;;;;fi;.tJr r entered just in the one general area that was marked by ,iirurorrrrO. This, of courr., *u, done after marking it with ultrasound' i.rU5i.tg the area with swabs to sterilize the area, and then using 20 cc of

1olo

ilOo.iii" for loca1 anesthesia. With a one-pass maneuver, we were able to get into some fluid. At flrst actually, we did not get anf f-igi{' We moved

overaboutlinch,andthen*"*t'"abletogetlOccoffluidbeforethe po.i."ipu*"red oui. The next one we got 5 cc, and I had to go to a different 'nocket io set that. Then in the fourth pocket we were able to get two

;rr;;;.fufit *irt 10 cc to get at least-4b cc of fluid' As this was such a tl*J"r area, I did not put"a chest tube in to drain it because I did not think we would get ffining that would amount to anything with the r*ili.t.tt tube"I had at -y-.o-*und' I think we might need tfroir.oi.opy to break up adhesions and drain it right' Of course' the

differentiaiof Utooay pleural fluid includes tuberculosis, ttauma, cancer,

""Jp"f*"nary embol-us. A ViQ scan would probably be pointless in this

pu*i."fur effoit. I think I would wait to see *hat the cultures are before

i*.rt oo*n the pulmonary embolus tree. I wili have to get a hold of Dr. Marrot about CT surgerY'

PATH0LoGYRE,PoRTLATERINDICATED:SeeReport67.

Copyright O 2015 by Saunders, an imprint of Eisevier Inc' A1l rights reserved'

APPEND1X A r Reports

rNDrcATroN: This is a 46-year-old white male with rourette,s and some MR who has had some hematochezia. There are no risk factors with no other symptoms.

PREoPERlrrrvE MEDTGATTONS: Fentanyl 100 mcg I[ versed 4 mg IV. FTNDTNGS: The Pentax video colonoscope was inserted without difficulty to the cecum. The ileocecal valve was identified. The appendiceal orifice was seen. I could not enter the cecum. Just above the valve, there was a small 2- to 3-cm polyp. This was hot biopsied off. There was a sessile 3-mm polyp in the proximal ascending colon, hot biopsied off. Inspection of the remainder of the ascending colon, hepatic flexure, transverse colon, splenic flexure, descending colon, and sigmoid colon, revealed no erythema, ulceration, exudate, friability, or other mucosal abnormalities. The rectum showed a small Z-mm polyp that was hot biopsied off. The patient tolerated the procedure well.

TMPRESSTON: Three small polyps, two in the cecum ascending colon area and one on the rectum, hot biopsied off.

PLAN: If these polyps are adenomatous/ the patient should return again in 5 years for surveillance.

PATHOLOGY REPORT LATER INDICATED: See Report 56.

PREOPERATM DIAGNOSIS: Nonhealing duodenal ulcer. POSTOPERATM DIAGNOSIS: Nonhealing duodenal ulcer. PROCEDURES PERFORMED:

1. Exploratory laparotomy. 2. P artial gastrectomy (antrectomy). 3. Truncal vagotomy. 4. Gastrojejunostomy. 5. Cholecystectomy with intraoperative cholangiogram. rNDrcATroN: The patient is a 60-year-old female who presented with a nonhealing gastric ulcer. She has had symptoms for about a year. She complains of epigastric pain. Medical therapy with prilosec failed, as did therapy for H. pylori. Biopsy of the ulcer has been done, and it was benign. The patient had a negative workup for gastrinoma. calcium level was also normal. The patient now presents for exploratory laparotomy and partial gastrectomy. The risks and benefits were discussed with the patient in detail. She understood and agreed to proceed.

PROCEDURE: The patient was brought to the operating room. Her abdomen was prepped and draped in a sterile fashion. A midline umbilical incision was made. The peritoneal cavity was entered. Initial inspection of the peritoneal cavity showed normal liver, spleen, colon, and small bowe1. There was an ulcer along the first portion of the duodenum just beyond the pylorus with some scarring. There was also an ulcer in the posterior part of the duodenal bulb, which was penetrating to the pancreas. we started dissection along the greater curvature of the stomach. vessels were ligated wrth 2-0 silk ties. There was an enlarged lymph node along the greater curvature of the stomach, which was sent for frozen section. It proved to be a benign lymph node. This was the only enlarged node found during dissection. we then proceeded with truncal vagotomy. The anterior r,agus