MEZIESKY
Guru
My Dr. went in to check a screw for bowel penetration after repair of a hip fx. There was nothing found. Not sure what diagnosis code to use. Op-Note to follow
PREOPERATIVE DIAGNOSIS: Right hip fracture with question of pelvic penetration of screw.
POSTOPERATIVE DIAGNOSIS: Right hip fracture with question of pelvic penetration of screw with a negative exploratory laparoscopy.
PROCEDURE: Exploratory laparoscopy.
ANESTHESIA: General endotracheal.
INDICATIONS FOR PROCEDURE: The patient is a 79-year-old gentleman who is undergoing hip pinning for fracture by Dr.XXX
when he felt that one of the pins had slightly passed, pointed into the pelvis. Because of the uncertainty as far as the depth of penetration a surgical consultation was obtained intraoperatively for further evaluation.
FINDINGS: No evidence of pelvic or intra-abdominal injury. Specifically, no hematomas were appreciated. There was no damage or bruising to the bowel or retroperitoneal structures.
ESTIMATED BLOOD LOSS: Minimal.
FLUIDS: Was 500 crystalloid.
SPECIMEN: None.
DRAINS: None.
COMPLICATIONS: None.
PROCEDURE IN DETAIL: The patient remained in the operative suite, was placed in a supine position after being transferred off the fracture table. His abdomen was then prepped and draped in a sterile fashion. After local infiltration, a supraumbilical incision was made, pneumoperitoneum achieved with the Veress. A 5 mm bladeless trocar was inserted, then under direct vision a left lateral 5 and a left suprapubic 5 mm port were placed. There was no succuss or debris in the abdomen. The patient had some adhesions in the right lower quadrant from a prior appendectomy. These were easily lysed, this gave visualization of the cecum, which was uninjured. There was no evidence of any blood or debris pooling in the pelvis which was clear. The iliac vessels were clear, as well as the ureter. Without evidence of any intraabdominal or pelvic injury, all ports were now removed and the abdomen desufflated. All skin was closed with subcuticular 4-0 Monocryl, Steri-Strips, and Band-Aids.
Patient tolerated procedure well, was taken to recovery area in satisfactory condition
Thank you for any help.
Marie
PREOPERATIVE DIAGNOSIS: Right hip fracture with question of pelvic penetration of screw.
POSTOPERATIVE DIAGNOSIS: Right hip fracture with question of pelvic penetration of screw with a negative exploratory laparoscopy.
PROCEDURE: Exploratory laparoscopy.
ANESTHESIA: General endotracheal.
INDICATIONS FOR PROCEDURE: The patient is a 79-year-old gentleman who is undergoing hip pinning for fracture by Dr.XXX
when he felt that one of the pins had slightly passed, pointed into the pelvis. Because of the uncertainty as far as the depth of penetration a surgical consultation was obtained intraoperatively for further evaluation.
FINDINGS: No evidence of pelvic or intra-abdominal injury. Specifically, no hematomas were appreciated. There was no damage or bruising to the bowel or retroperitoneal structures.
ESTIMATED BLOOD LOSS: Minimal.
FLUIDS: Was 500 crystalloid.
SPECIMEN: None.
DRAINS: None.
COMPLICATIONS: None.
PROCEDURE IN DETAIL: The patient remained in the operative suite, was placed in a supine position after being transferred off the fracture table. His abdomen was then prepped and draped in a sterile fashion. After local infiltration, a supraumbilical incision was made, pneumoperitoneum achieved with the Veress. A 5 mm bladeless trocar was inserted, then under direct vision a left lateral 5 and a left suprapubic 5 mm port were placed. There was no succuss or debris in the abdomen. The patient had some adhesions in the right lower quadrant from a prior appendectomy. These were easily lysed, this gave visualization of the cecum, which was uninjured. There was no evidence of any blood or debris pooling in the pelvis which was clear. The iliac vessels were clear, as well as the ureter. Without evidence of any intraabdominal or pelvic injury, all ports were now removed and the abdomen desufflated. All skin was closed with subcuticular 4-0 Monocryl, Steri-Strips, and Band-Aids.
Patient tolerated procedure well, was taken to recovery area in satisfactory condition
Thank you for any help.
Marie
