Hello. Stuck on this one. I'm not sure what to even code here, or how. Procedure as follows:
PREOPERATIVE DIAGNOSIS/DIAGNOSES
Remote history of coronary artery bypass grafting, recent fall, mediastinal mass.
POSTOPERATIVE DIAGNOSIS/DIAGNOSES
Remote history of coronary artery bypass grafting, recent fall, mediastinal mass.
ANESTHESIA
Anesthesiologist Dr. XYZ.
SPECIMENS
No explants.
IMPLANTS/HARDWARE
None.
INDICATION FOR PROCEDURE
The patient is a X-year-old patient who has had a history of remote coronary artery bypass grafting. He has been admitted with expanding mass on the chest wall with an INR that was 7. This has been corrected. He is being brought to the operating room for exploration.
DESCRIPTION OF PROCEDURE
After induction of general endotracheal anesthesia, the areas were prepped and draped in a sterile fashion. The old sternotomy incision was opened and there was a large amount of fat necrosis that was encountered with the second wire that had pulled through in the upper sternum. This was removed and the entire subcutaneous space irrigated with saline and antibiotic lavage. A wound VAC was then placed to help with secondary healing.
ESTIMATED BLOOD LOSS
100 milliliters.
COMPLICATIONS
None.
PREOPERATIVE DIAGNOSIS/DIAGNOSES
Remote history of coronary artery bypass grafting, recent fall, mediastinal mass.
POSTOPERATIVE DIAGNOSIS/DIAGNOSES
Remote history of coronary artery bypass grafting, recent fall, mediastinal mass.
ANESTHESIA
Anesthesiologist Dr. XYZ.
SPECIMENS
No explants.
IMPLANTS/HARDWARE
None.
INDICATION FOR PROCEDURE
The patient is a X-year-old patient who has had a history of remote coronary artery bypass grafting. He has been admitted with expanding mass on the chest wall with an INR that was 7. This has been corrected. He is being brought to the operating room for exploration.
DESCRIPTION OF PROCEDURE
After induction of general endotracheal anesthesia, the areas were prepped and draped in a sterile fashion. The old sternotomy incision was opened and there was a large amount of fat necrosis that was encountered with the second wire that had pulled through in the upper sternum. This was removed and the entire subcutaneous space irrigated with saline and antibiotic lavage. A wound VAC was then placed to help with secondary healing.
ESTIMATED BLOOD LOSS
100 milliliters.
COMPLICATIONS
None.