bevann0402@bellsouth.net
Networker
- Messages
- 60
- Best answers
- 0
its unplanned return to OR, so I know which modifier I will need to use, but the CPT codes to start looking at is confusing me..
Preoperative diagnoses:
1. abdominal pain
2. diarrhea
3. vaginal bleeding
4. history of advanced endometrial cancer
Postoperative diagnoses"
1. cystoscopy done by Dr Holcomb with mass under trigone with vaginal evaluation showing drainage of mass of pelvic hematoma, approx. 800 cc.
Operation:
1. pelvic hematoma evacuation under general anesthetic with vaginal exam
2. drainage of pelvic hematoma
3. placement of 0.25 inch penrose drain with a vag pack
4. c&s were performed
Procedure:
the patient was seen in consultantion prior. the patient was being evaluated by Dr. Holcomb for cystoscopy for possible pelvic mass. an examination was performed under general anesthetic in the lithotomy position. A sterile speculum exam was performed. there was tension noted on the dome of the vagina with irritation. there was old blood coming from the lateral aspects of the vaginal cuff. no gross mass could be noted. the area was then suctioned. a small amount of blood was noted on the left. when exploring the right, a large amount of old blood was noted. gram stain, aerobic and anaerobic culture and sensitivity was performed. this was suctioned clear. there appeared to be a deep pocket. further blood was removed. no further bleeding was noted. this was then measured approximately 6 to 8 cm in depth. all areas were reexamined. no other findings were noted. the tension on the superior aspect of the vaginal cuff was gone. probably the tinting that Dr Holcomb saw on the trigone was possibly due to the hematoma. it was elected to place a penrose drain. this was radiopaque, 0.25 inch drain placed into the right lateral vaginal opening. a vag pack was carefully place, leaving the drain exposed out. the patient was then covered with a dressing. the first and second
sponge , instrument and needle counts were found to be correct. the patient tolerated the procedure well.
thanks to all in advance for any help,
Beverly, CPC
Preoperative diagnoses:
1. abdominal pain
2. diarrhea
3. vaginal bleeding
4. history of advanced endometrial cancer
Postoperative diagnoses"
1. cystoscopy done by Dr Holcomb with mass under trigone with vaginal evaluation showing drainage of mass of pelvic hematoma, approx. 800 cc.
Operation:
1. pelvic hematoma evacuation under general anesthetic with vaginal exam
2. drainage of pelvic hematoma
3. placement of 0.25 inch penrose drain with a vag pack
4. c&s were performed
Procedure:
the patient was seen in consultantion prior. the patient was being evaluated by Dr. Holcomb for cystoscopy for possible pelvic mass. an examination was performed under general anesthetic in the lithotomy position. A sterile speculum exam was performed. there was tension noted on the dome of the vagina with irritation. there was old blood coming from the lateral aspects of the vaginal cuff. no gross mass could be noted. the area was then suctioned. a small amount of blood was noted on the left. when exploring the right, a large amount of old blood was noted. gram stain, aerobic and anaerobic culture and sensitivity was performed. this was suctioned clear. there appeared to be a deep pocket. further blood was removed. no further bleeding was noted. this was then measured approximately 6 to 8 cm in depth. all areas were reexamined. no other findings were noted. the tension on the superior aspect of the vaginal cuff was gone. probably the tinting that Dr Holcomb saw on the trigone was possibly due to the hematoma. it was elected to place a penrose drain. this was radiopaque, 0.25 inch drain placed into the right lateral vaginal opening. a vag pack was carefully place, leaving the drain exposed out. the patient was then covered with a dressing. the first and second
sponge , instrument and needle counts were found to be correct. the patient tolerated the procedure well.
thanks to all in advance for any help,
Beverly, CPC