After full explanation of the procedure, the parents signed the consent form. The patient was escorted into the procedure room by her parents where she was sedated.
24. Scenario 2
HISTORY
The patient is a 5-year-old female who was practicing for a ballet recital. As she was completing a pirouette, she twisted her knee and fell to the ground. To ensure that permanent damage had not occurred, the orthopedist felt a diagnostic arthroscopy of her knee should be done.
PROCEDURE
After full explanation of the procedure, the parents signed the consent form. The patient was escorted into the procedure room by her parents where she was sedated. The incision site was prepped and draped. Injection of a saline solution distended the joint. The arthroscope was advanced into the joint through a small skin incision. The exploration revealed a complex lateral meniscus tear of the right knee. A meniscal repair was then scheduled. The arthroscope was removed. Minimal bleeding was noted and the site was covered with sterile dressing. The patient tolerated the procedure well and was taken to the operating room for further care.
Note: External cause code(s) apply, but external cause status is not necessary.
ICD-10-CM: _____ CPT: _____
ICD-10-CM: _____
28. Scenario 6
PREOPERATIVE DIAGNOSIS
Rectal prolapse.
POSTOPERATIVE DIAGNOSIS
Rectal prolapse.
PRIMARY PROCEDURE ABDOMINAL PROCTOPEXY.
PROCEDURE
The patient was taken to the operating room and placed on the table in the supine position. After the induction of anesthesia by the general endotracheal technique, bilateral lower extremity pneumatic compression stockings were placed. A Foley catheter was placed, and a rectal tube was placed for subsequent irrigation and testing of the proctopexy procedure.
After standard prep and drape, a midline celiotomy incision was created entering into the peritoneal cavity and subsequent exploration was without discovery of any pathology with exception of extreme laxity of the mesentery of the entire colon and a tremendous amount of redundant colon.
Attention was then directed to the rectosigmoid region where peritoneal reflections were taken down bilaterally with specific identification and protection of both ureters. The peritoneal reflection was then divided in the caudad direction, and the rectosigmoid and rectum were mobilized from the sacral hollow utilizing a combination of sharp and blunt dissection.
Once the rectum has been freed to the level of the tip of the coccyx, it was brought up under modest tension into the operative field and reflected to the patient’s left. An inverted T-shaped piece of Gore-Tex soft tissue patch was then fashioned and was subsequently secured to the sacral hollow up to the point of the sacral promontory utilizing a series of interrupted 0 Gore-Tex sutures. Subsequently the rectum was placed in mild tension within the span of 2 limbs of Gore-Tex soft tissue patch and subsequently encircled by those limbs. These were each then packed at multiple points to the rectum utilizing a series of interrupted 2-0 Prolene sutures placed in seromuscular fashion. Once the tacking procedure was done, the pelvis and retroperitoneum were irrigated with saline and evacuated.
The rectum was then irrigated with saline placed via the rectal tube and was noted to expand easily within the confines of the noncircumferential Gore-Tex sling. The rectum was then evacuated.
The midline fascia was then closed utilizing #1 Prolene suture in continuous running fashion. The subcutaneous tissue was irrigated, and the skin was closed with stainless steel clips. A sterile dressing was applied. Patient was aroused from his anesthetic, extubated in the operating room and transported to the PAR in stable condition.
ICD-10-CM: _____ CPT: _____
29. Scenario 7
PREOPERATIVE DIAGNOSIS
Endometrial intraepithelial neoplasia, grade III, on cervical biopsy and endocervical curettage.
POSTOPERATIVE DIAGNOSIS
Endometrial intraepithelial neoplasia, grade III, on cervical biopsy and endocervical curettage.
PRIMARY PROCEDURE
CONE BIOPSY.
ENDOCERVICAL CURETTAGE.
ENDOMETRIAL CURETTAGE WITH BIOPSY.
FINDINGS AND PROCEDURE
After the induction of adequate general endotracheal anesthesia, the patient was placed in the dorsal lithotomy position. Examination under anesthesia demonstrated a small cervix and uterus without any adnexal masses. The cervix was firm to palpation. The speculum demonstrated a cervix that was smooth and without lesions. Colposcopy was performed and was noted to be unsatisfactory. No lesions were seen. Cone biopsy was then performed with a sound in the cervix. This was difficult to accomplish due to the cervix being flush with the uterus. The cone biopsy was tagged at 12 o’clock. No cone tip was cut. Endocervical curettage was performed. Endometrial curettage was then performed. The uterus sounded to 4 cm, and scant tissue was obtained. Hemostasis was then assured. The Bovie was used to control any bleeding. Patient tolerated the procedure satisfactorily; however intraoperatively the patient did have an increased blood pressure that was controlled quickly with nadolol. The patient’s blood pressure then was stable at 120/60. Anesthesia: General endotracheal. Estimated blood loss: 10 mL. Intravenous fluids: 1600 mL. Lines: IV and arterial line. Urinary output during the procedure: 700 mL. Drains: None. Count: Correct.
The specimens that were sent to pathology: (1) Cone biopsy, (2) endocervical curettage, (3) endometrial curettage. Urine was sent for cytology.
ICD-10-CM: _____ CPT: _____
CPT: _____
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