1. this case study has 2 diagnoses codes and 1 procedure codes…. 1. this case study has 2

1. this case study has 2 diagnoses codes and 1 procedure codes…. 1. this case study has 2 diagnoses codes  and 1 procedure codes.Outpatient SurgeryPatient Case Number: OPSX32-Sandall, OscarPatient Name: Oscar SandallDOB: 02-19-72Sex: MDate of Service: 05-05-XXSurgeon: Sandra Cullman, MDPre-Operative DiagnosisRight knee complex medial meniscus tearPost-Operative DiagnosisRight knee complex medial meniscus tear and medial plicaProcedure Performed: Knee arthroscopy w/ partial medial meniscectomy, chondroplasty of medial femoral condyle, excision of medial plicaAnesthesia: GeneralComplications: None Indication for Procedure:The patient is a 46y/o male who was referred to me with complaints of right knee pain. He has had pain for several months and failed nonoperative treatment. I recommended a right knee arthroscopy with partial medial meniscectomy. The risks, benefits and possible complications from the surgery were discussed in detail and the patient wishes to proceed. The potential risks include: Infection, bleeding, neurovascular damage, residual pain and dysfunction, recurrence as well as the surgery possibly not improving the patient’s symptoms. If a meniscectomy is performed the patient understands that there is an increased chance of developing or accelerating any existing arthritis in that knee. The patient also understands the risks of anesthesia which include stroke, heart attack, aspiration, blood clot, pulmonary embolus and death. Description of Procedure:After consent was obtained the patient was taken to the operating room and was administered a general anesthetic and intubated. A well-padded tourniquet was applied to the right upper thigh. The extremity was then prepped and draped in the usual fashion. An Esmarch was used to exsanguinate the right lower extremity and the tourniquet inflated to 325 mmHg. a superomedial portal was made for the introduction of the inflow. An anterolateral portal was made for the introduction of the arthroscope. An anteromedial portal was made for the introduction of arthroscopic instruments. The findings are as follows: Suprapatellar pouch: NormalMedial plica: FrayedMedial gutter: NormalLateral gutter: NormalPatella: NormalTrochlea: Grade I Chondromalacia – Softening Articular CartilageMedial Femoral Condyle: Grade IIA Chondromalacia – Fissures/Fragmentation Articular Cartilage <50% and Grade 118 Chondromalacia -Fissures/Fragmentation Articular Cartilage >50%Medial meniscus: Tear, Complex- Root, Posterior Horn, BodyMedial Tibial Plateau: NormalACL: NormalPCL: NormalLateral Femoral Condyle: NormalLateral Meniscus: NormalLateral Tibial Plateau: NormalPopliteus: NormalPopliteal Hiatus: NormalA partial medial meniscectomy was performed. Using a combination of an upbiting basket, straight basket and a 4.2 mm Cuda shaver I removed 50 % of the root, 75 % of the posterior horn, 25 % of the body and 0 % of the anterior horn of the medial meniscus. The rim was smoothed with a 4.2 mm Tiger shaver. A 4.2 mm Cuda shaver was used to remove the medial plica. A chondroplasty was performed of the medial femoral condyle. A 4.2 mm tiger shaver was used to debride the unstable, fibrillated articular cartilage. The portals were closed with 3-0 Prolene suture. The knee was injected with 10 cc of 0.25% Marcaine and 5 mg of Duramorph. A sterile dressing was applied with a Polar Care pad incorporated into the dressing. The tourniquet was deflated at 18 minutes. The patient was awakened and extubated by anesthesia and taken to the recovery room in stable condition. The patient tolerated the procedure well with no immediatecomplications.Post-op Condition of Patient: Stable Electronically Signed By: Sandra Cullman, MD Copyright © 2020 by The American Health Information Management Association. All Rights Reserved.2. case study has 2 diagnoses codes and one procedure codes. Outpatient SurgeryPatient Case Number: OPSX31-Mayweather, CoraPatient Name: Cora MayweatherDOB: 03-01-66Sex: FDate of Service: 08-13-XXSurgeon: Matthew Bordelon, MDPre-Operative Diagnosis Metastatic stage IIIC cancer of ovary w/ involvement of the rectosigmoidcolon and ovariesPost-Operative DiagnosisMetastatic stage IIIC cancer of ovary w/ involvement of the rectosigmoid colon and ovariesProcedure Performed: Insertion of single-lumen infusaport, debridement of necrotic tissue around stoma, removal of PICC lineAnesthesia: GeneralComplications: None PREOPERATIVE DIAGNOSES:Metastatic stage IIIC cancer of the ovary with involvement of the rectosigmoid, both the ovaries and the cul-de-sac, status post ovarian cancer debulking.Lack of vascular access. POSTOPERATIVE DIAGNOSES:Metastatic stage IIIC cancer of the ovary with involvement of the rectosigmoid, both the ovaries and the cul-de-sac, status post ovarian cancer debulking.Lack of vascular access. OPERATIVE PROCEDURE CARRIED OUT:Insertion of a single-lumen infusaport.Debridement of necrotic tissue around the stoma.Removal of PICC line. DESCRIPTION OF PROCEDURE:After successful induction of general anesthesia, the patient was placed in steep Trendelenburg position. The neck and the chest wall was prepped and draped in the usual sterile fashion. An infraclavicular subclavian puncture was then made. Guidewire was inserted into the right atrium. The needle was then removed. The position of the guidewire was tested radiographically. A dilator introducer kit was inserted over the guidewire into the right atrium. The right guidewire was removed. The catheter was inserted into the right atrium under fluoroscopic guidance. A transverse incision was then made on the anterior chest wall. Subcutaneous tissue was incised along the line of the incision. The catheter was tunneled subcutaneously to the point on the anterior chest wall. The catheter was connected to the reservoir such that the tip of the catheter was located in the right atrium. The catheter was then attached to the reservoir. The reservoir was then flushed. The reservoir was sutured to the anterior chest wall. The patient tolerated the procedure well. The skin was closed with subcuticular suture. The skin was closed with subcuticular sutures. The patient tolerated the procedure well. The patient was transferred to the recovery room under satisfactory conditions. The PICC line was removed by gentle traction. The tip of the catheter was intact. A sterile dressing was applied on the right arm where the PICC line has been taken out. The ostomy in the left lower quadrant was revisualized. The tissue around the colostomy was excised. A new colostomy bag was then placed over this site. Minimal debridement of necrotic tissue around the base of the stoma was carried out and by sharp dissection. Dictating Clinician: Matthew Bordelon, MD Electronically Signed By: Matthew Bordelon, MD Copyright © 2020 by The American Health Information Management Association. All Rights Reserved.          Health Science Science Nursing HIMT 2224 Share QuestionEmailCopy link Comments (0)

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