Please check ICD-9-CM codes to be correct for the operative reports
7.34 Discharge Summary
Date of Admission: 1/3
Date of Discharge: 1/7
Discharge Diagnosis: Recurrent carcinoma, left lung
This is a 63-year-old female who is two years status post left upper lobe resection for adenocarcinoma. Pathology at that time revealed a positive bronchial margin of resection. She was treated with postop radiation and has done extremely well. She has remained asymptomatic with no postoperative difficulty. Follow-up serial CT scans have revealed a new lesion in the apical portion of the left lung, which on needle biopsy was positive for adenocarcinoma. She was admitted specifically for a left thoracotomy and possible pneumonectomy.
Past Medical History: Positive for tobacco abuse 2 PPD x 30 years in the past. Significant for a right parotidectomy and also significant for hypertension, degenerative joint disease of lumbar spine, and chronic pulmonary disease. The patient also suffered a stroke in the left brain with resulting hemiparesis three years ago. Medications on discharge: Tenormin 25 mg once a day, Calan SR 240 mg twice a day, Moduretic one tablet q. day, K-Dur 10 meq q. day, Proventil MDI 2 puffs POq.i.d. p.r.n., Azacort MDI 2 puffs PO ti.d., Vioxx 25 mg PO daily.
Physical Examination: Revealed a well-healed right parotid incision. No supraclavicular adenopathy. She has a healed left posterior lateral thoracotomy scar. Impression is that of local recurrence, status post left upper lobectomy. She is to undergo a left pneumonectomy.
Operative Findings and Hospital Course: There was a large mass in the remaining lung, extensive mediastinal fibrosis, bronchial margin free by frozen section. Following surgery she was placed in the intensive care unit postoperatively. The chest tube was removed on postoperative day number two. She experienced some EKG changes consistent with acute nontransmural MI. Cardiology was consulted, and she was started on nitroglycerin and IV heparin. She was eventually weaned from her oxygen therapy.
She was started on regular diet and was discharged in good condition. Her wound was clean and dry.
Instructions on Discharge: Discharged home with instructions to follow up with cardiology next week. Also follow up with me in the office.
History and Physical
History of Present Illness: Patient is a 63-year-old right-handed female with history of recurrent adenocarcinoma of apical segment of left upper lobe of lung. She has received radiation therapy to her chest. She weighs 123 pounds. She also has chronic obstructive pulmonary disease.
Review of Systems: She can climb two flights of steps with minimal difficulties.
She has a significant underbite. She has stiffness in lower spine, worse in the a.m. She has hypertension and took her Tenorrnin 25 mg, Calan SR 240 mg this a.m.
Past Surgical History: She had a right parotidectomy seven years ago and was told they needed to use a “very small” ETT. Two years ago she underwent a left upper lobe resection at this facility. Previous medical records are being requested.
Allergies: She is allergic to sulfa. Postoperatively last time she received Demerol. She also had hallucinations in the ICU for several days. She blames the hallucinations on the Demerol. The only allergy sign was hallucinations.
Physical Examination: Revealed a well-healed right parotid incision. No supraclavicular adenopathy. She has a healed left posterior lateral thoracotomy scar. Impression is that of local recurrence, status post left upper lobectomy. She is to undergo a left completion pneumonectomy, muscle flap coverage of bronchial stump. The patient has hemiparesis in the right extremities.
Impression: Recurrent carcinoma left lower lobe of lung
Plan: Pneumonectomy of left lung. The patient is agreeable to general endotracheal anesthesia or the use of epidural narcotic. She is agreeable to postoperative ventilation if necessary.
1/3 Attending Physician: Admit for recurrent lung carcinoma, sip radiation therapy. Consent signed for pneumonectomy. Epidural morphine usage postop explained to and discussed with the patient. She is agreeable.
Anesthesia Preop: Patient evaluated and examined. General anesthesia chosen. Patient agrees. Will provide postop epidural morphine for pain management sip thoracotomy.
Preop Dx: Local recurrence of carcinoma of the lung
Postop Dx: Same
Procedure: Pneumonectomy with muscle flap coverage of bronchial stump
Complications: RIO intraop MI
Anesthesia Postop: Patient in stable condition following GEA with possible intraoperative MI due to hypotension. CPK to be evaluated as available. Patient comfortable with epidural morphine. No adverse effects of anesthesia experienced.
1/4 Attending Physician: Path report confirms recurrent adenocarcinoma. Patient stable but with persistent hypotension resolving slowly-will consult cardiology. CPK MB positive. Incision clean and dry. COPD stable, arthritis stable.
Cardiology Consult: The patient has resolving intraoperative myocardial
infarction. Will continue to monitor.
1/5 Attending Physician: Looks and feels well, weaning off morphine. Blood pressure stable. Left pleural space expanding and filling space. Chest tube removed, epidural cath removed.
Cardiology Consult: The patient looking and feeling better.
1/6 Attending Physician: Patient stable for discharge in a.m. Cardiology to follow.
Preoperative Diagnosis: Recurrent carcinoma of left lung
Postoperative Diagnosis: Same
Anesthesia: General endotracheal anesthesia
Operative Findings: There was a large mass in the left lower lobe. The patient was prepped and draped in the usual fashion. Following thoracotomy the left lung was completely removed. A muscle flap coverage was used for the bronchial stump. During the procedure the patient experienced an episode of hypotension, watch for resulting MI. The patient was fluid resuscitated and sent to the recovery room in good condition.
Specimen: Left lung, resected
Clinical Data: This is a 63-year-old female with recurrent disease on CT scan
Diagnosis: Adenocarcinoma of the apical portion of the lung, bronchial margin is free of disease
Chest X-Ray: Reveals mass in the left lower lobe. There are surgical clips in the thorax from apparent previous surgery. The thoracic organs are midline and the vasculature is normal.
Impression: Carcinoma LLL, no congestive heart failure
Chest X-Ray: Reveals absence of left lung. Other architecture is normal other than post-operative changes. The thoracic organs are midline and the vasculature is normal.
Impression: Postop changes consistent with lobectomy, no congestive heart failure.
Normal sinus rhythm
There are nonspecific ST changes consistent with possible evolving myocardial infarction.
Possible acute myocardial infarction, please correlate with other clinical findings.
Are these codes correct? 162.5, 997.1, 410.71, 401.1, 458.29, 721.3, 438.21, V15.82, V45.76
7.44. The following documentation is from the health record of a 13-year-old boy.
Preoperative Diagnosis: Right inguinal hernia, hypospadias
Postoperative Diagnosis: Same
Operation: Right inguinal herniorrhaphy, repair of hypospadias
Indications: The patient is a 13-year-old male with reducible right inguinal hernia and hypospadias who now presents for definitive care.
Procedure: The patient was brought to the operating room and placed in the supine position. After the adequate general endotracheal anesthesia, a 4-cm incision was made in the right inguinal region. The subcutaneous tissues were divided, and hemostasis achieved with electrocautery. The external oblique fascia was identified and cleaned using Metzenbaum scissors. An incision was made in the external oblique and carried down to the external ring using Metzenbaum scissors. The external oblique was freed from the underlying cord using two pairs of forceps. The cremasteric fibers were divided and the hernia sac grasped. Pulling the hernia sac up on some tension, we were then able to tease off the cremasteric fibers, as well as the vas and vessels. At this point, we were able to control the hernia sac between the two hemostats. We then teased off the vas and vessels as we dissected proximally toward the internal ring. At this point, the sac was twisted, sutured ligated, X 2, amputated, and then the sac was allowed to fall back into the peritoneal cavity. We continued the dissection distally. The anterior wall was opened using electrocautery. At this point, we placed the cord back into the inguinal canal. The external oblique fascia was closed using interrupted 4-0 silk sutures. The external oblique fascia and the structures below it were infiltrated using .05 percent Marcaine. The Scarpa’s fascia was closed using 5-0 VICRYL. The skin was closed using interrupted 5-0 subcuticular stitches. Steri-Strips were applied.
With this completed, attention was then turned to repairing the hypospadias. Procedure commenced by placing a 4-0 Prolene stay suture through the glans for traction and observing the distal shaft hypospadias without chordee and with a dorsal hooded foreskin.
The urethroplasty was begun by making parallel lines with a marking pen on either side of the urethral meatus, going out to the tip of the glans, connecting these proximally from the meatus for a distance of about 2.5 em. With a tourniquet used intermittently, an incision was made in these lines to create two rectangular flaps connected at the urethral meatus. On the left side of the meatus there was a small nevus just lateral to the incision line, and the incision was extended around this to excise a small nevus, less than 0.6 em in diameter, which will be sent for pathology. After mobilization of both skin flaps, the proximal one off of the shaft and the ventral one off of the underlying tissue of the glans, optical magnification was used to convert these two flaps into a neourethral tube using 6-0 PDS sutures. The neourethral tube came together quite well.
Next, an incision was made in the midline, out to the tip of the glans, through the incision point at the previous site of the distal flap, to accomplish mobilization of the urethra and advance this urethra out to the tip of the glans. Wedge-shaped areas of glandular tissue were excised to make a smooth passageway for the neourethra. Then the neourethra was sutured into position at the tip of the glans with 6-0 and 5-0 PDS sutures.
Next, a second layer was created by approximating the subcutaneous tissue, adventitial tissue, and elements of the corpus spongiosum over the neourethral reconstruction at the corona, and carrying this with a running 6-0 PDS suture proximally to provide a second layer of coverage.
When this was done, the glans itself was approximated with 4-0 PDS sutures, placing about three sutures into position to firmly reconnect the wings of the glans and to keep them from pulling apart. This left an aperture for the neourethra, which was then sutured into position with 4-0 and 5-0 PDS sutures. When this was done, a #11 French Silastic catheter was used, and a portion of its wall was cut out to turn it into a splint. It was positioned into the urethra and sutured into place at the meatus with a 4-0 Prolene suture to hold it into position. The next step was to close the skin defect on the ventral shaft with interrupted 3-0 chromic catgut suture.
The next part of the operation involved performing circumcision of the redundant dorsal and lateral preputial tissue. First, this was marked with a marking pen, and then an incision was made in the pen lines to allow excision of the redundant foreskin. Hemostasis was obtained with electrocautery, and 3-0 chromic catgut suture was used to complete the circumcision.
The next step was to consider the ability of this patient to void. Because of his hernial repair and this operation on the prepuce, I was afraid he would be in urinary retention. I therefore inserted a #8 French feeding tube through the #11 French Silastic catheter, passed it all the way into the bladder, and allowed it to drain urine freely. Then a light sterile dressing of l-inch Adaptic roller gauze soaked in tincture of benzoin was loosely wrapped around the shaft for mild compression and hemostasis. The last few wraps of this incorporated the catheter.
The patient was taken to the recovery room in satisfactory condition.
Are these codes correct? 752.61, 605, 550.90, 187.4, 58.45, 53.02, 64.0, 64.11, 57.94
The post This is a 63-year-old female who is two years status post left upper lobe resection for adenocarcinoma. Pathology at that time revealed a positive bronchial margin of resection. She was treated with postop radiation and has done extremely well. She has remained asymptomatic with no postoperative difficulty. Follow-up serial CT scans have revealed a new lesion in the apical portion of the left lung, which on needle biopsy was positive for adenocarcinoma. She was admitted specifically for a left thoracotomy and possible pneumonectomy. appeared first on commompapers.org.