Operative Report

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Operative Report

Operative Report

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M132 Module 08 Coding Assignment

Build the correct ICD 10 PCS code based on the documentation in the Operative Report documentation given under each Case Study.

1. Case #1

PREOPERATIVE DIAGNOSES:

1. A 37 weeks intrauterine pregnancy.

2. Previous cesarean section with rupture of membranes.

POSTOPERATIVE DIAGNOSES:

1. A 37 plus weeks gestation.

2. Previous cesarean section with spontaneous rupture of membranes.

3. Pelvic adhesions.

ANESTHESIA: Spinal.

PROCEDURE PERFORMED: Repeat low-transverse cesarean section.

FINDINGS: Male infant, 6 pounds, 5 ounces. Apgars 9 and 9.

ESTIMATED BLOOD LOSS: 800 mL.

The patient’s condition after surgery, the patient tolerated the procedure well.

PERTINENT HISTORY AND PHYSICAL: The patient is a 20-year-old black female, gravida 2, para 1-0-0-1, last normal menstrual period 08/02/2006, EDC 05/08/2007, 37-5/7th weeks gestation, she presented to L D with spontaneous rupture of membranes, history of previous cesarean section in 2009 for CPD.

PAST MEDICAL HISTORY: She denies allergies.

MEDICATIONS: She is on prenatal vitamins.

MEDICAL SURGICAL: She denies any significant history except for C-section in 2006.

SOCIAL HISTORY: She denies ethanol, tobacco, or drugs.

PSYCHIATRIC HISTORY: Noncontributory.

FAMILY HISTORY: Noncontributory.

PHYSICAL EXAMINATION: Vital Signs: Temperature, the patient is afebrile, pulse 94, respiratory rate 20, BP 97/50, fetal heart tone was 140 to 145. HEENT was within normal limits. Neck is supple. Chest: Cardiovascular, Sl and S2 regular without gallop or murmur. Lungs: Clear both fields. Breasts: No masses or tenderness. Abdomen: Gravid. Pelvic: Cervix was 50% effaced, 1 to 2 cm dilated, presenting part was vertex at -2 station, there was gross fluid, clear and Nitrazine was positive. The patient was therefore taken to the operating room for a repeat low-transverse cesarean section.

OPERATIONAL TECHNIQUE: The patient was brought to the operating room and under spinal anesthesia, was prepped and draped in the usual manner for a gynecologic abdominal operation. Through the old suprapubic Pfannenstiel skin incision, the abdominal cavity was entered into after much difficulty because of the pelvic abdominal adhesion. Following entry into the abdominal cavity, the bladder peritoneum was identified, reflected down. Following that, a midline low-transverse incision was made at the lower uterine segment with a knife and carried down into the uterine cavity without any difficulty. The incision was then extended to the level of the round ligament on both sides. Following which a male infant in vertex position was delivered with vacuum and handed over to the nursery staff in attendance. Birth weight was 6 pounds 5 ounces. Apgar was 9 and 9. Placenta was manually delivered. After remnants of the placental membranes have been removed from the uterine cavity, the uterine cavity was then closed with #1 chromic continuous interlocking suture. Hemostasis was verified and found to be adequate. The ovaries and tubes were inspected and found to be within normal limits. The abdominal cavity was copiously irrigated. The abdominal cavity was then closed in layers. The pyramidal muscle was closed with 2-0 interrupted suture, the fascia was closed with #1 Vicryl continuous suture in two halves and the skin was closed with staples. The patient tolerated the procedure well and left the operating room, awake, conscious, and in excellent condition.

ESTIMATED BLOOD LOSS: 800 mL

ICD-10-PCS Code: Click here to enter text.

2. Case Study #2

Electroencephalogram

Description: This is an 18-channel digital EEG recording done on this 79-year-old male with a chief complaint of altered mental status .This patient is also on insulin for diabetes.

There is diffuse slowing and disorganization in the background consisting of medium-voltage theta rhythm at 4-6 Hz seen from all head areas. There was faster activity at beta range from the anterior. Eye movements and muscle artifacts are noted. EKG artifacts at 76 per minute were noted. Hyperventilation and Photic stimulation were not completed.

Findings: This is a moderately abnormal record due to diffuse slowing and disorganization of the background, with the slowing being at theta range. There is indication of a moderate encephalopathic condition. Clinical correlation is required to rule out a structural lesion.

ICD-10-PCS Code: Click here to enter text.

3. Case #3

PREOPERATIVE DIAGNOSIS: Cardiogenic shock.

POSTOPERATIVE DIAGNOSIS: Cardiogenic shock.

PROCEDURE PERFORMED: Insertion of extracorporeal membrane oxygenation circuit.

ANESTHESIA: General.

OPERATIVE INDICATIONS: The patient a 52-year-old African American male who previously had placement of a HeartMate II left ventricular assist device. The device seems to be nonfunctional at this time despite multiple pressor support. He has continued to develop cardiogenic shock and multisystem organ failure. ECMO circuit is indicated to help stabilize him prior to a planned device exchange.

OPERATIVE TECHNIQUE: The patient was placed on the OR table in the supine position. General anesthesia was induced. He was prepped and draped in the usual sterile fashion. A small transverse incision was made in the right groin and right femoral artery and vein isolated. A 10-mm Hemashield graft was then sewn end to side to the common femoral artery after administration of intravenous heparin. The Hemashield graft was then tunneled subcutaneously to

exit the skin in the upper thigh. A 29-French percutaneous venous cannula was then placed in the femoral vein without difficulty. The cannula was then attached to the ankle circuit and flow initiated. There was excellent flow with excess of 6 liters per minute. Transesophageal echo showed good cannula placed in the right atrium. There was significant coagulopathic bleeding from the femoral artery which took in excess of 2 hours to control with various hemostatic agents. Eventually, hemostasis was assured and the wound closed in layered closure of Vicryl and subcuticular stitch for skin. The patient was returned to the ICU in critical condition.

ICD-10-PCS Code: Click here to enter text.

4. Case Study #4

Report of Operation

Preoperative Diagnosis: Retained products of conception

Postoperative Diagnosis: Retained products of conception

Procedure: Suction and D and C

Estimated blood loss: 50 cc

Fluids: 150 cc LR

Urine Output: 10 cc clear

Anesthesia: Spinal

Specimens: Products of Conception

Complications: None

Condition: Stable to Recovery Room

Procedure: The patient was taken to the operating room where spinal anesthesia was found to be adequate. She was prepped and draped in the normal sterile fashion and placed in the dorsal supine position lithotomy. A bivalve speculum was placed in the vagina. The cervix was adequately visualized. The anterior cervix was grasped with a one-tooth tenaculum and uterus was gently pulled forward. The uterus was gently sounded to approximately 7 cm and dilated to 10 mm. A 10 mm suction curet was then gently advanced into the uterus. The suction device was attached and suction was started and suction dilation and curettage was performed gently without difficulties. Some products of conception were obtained through the suction canister. Three passes were done with the suction curet. Excellent hemostatsis was noted. The one-tooth tenaculum was removed from the anterior lip of the cervix. The patient was noted to be hemostatic. All instruments were removed. The patient tolerated the procedure well and was taken to the recovery room in stable condition.

ICD-10-PCS code: Click here to enter text.

Operative Report

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