rockylopez
Networker
Hello. I need assistance with this op report contemplating on cpt code 57023?
PREOPERATIVE DIAGNOSES:
1. Vulvar hematoma, ruptured
POSTOPERATIVE DIAGNOSES: Same as above
NAME OF PROCEDURE: exploration of ruptured vulvar hematoma
ANESTHESIA: GETA
ESTIMATED BLOOD LOSS: 1000 cc
FINDINGS: 5cm depth by 3cm width, extension superiorly to mons pubis
COMPLICATIONS: None.
DRAINS: Foley catheter.
SPECIMENS: none
COUNTS: Correct x3.
DVT PROPHYLAXIS: SCDs in place and the onset of the case
PREOPERATIVE ANTIBIOTICS: Ancef 1 grams
DESCRIPTION OF PROCEDURE: The patient was taken back to the operating room where patient was appropriately anesthetized with the GETA anesthesia. A timeout was then performed verifying the correct patient, the correct procedure, and the correct diagnosis. Once everyone in the room was in agreement the procedure was started. The patient was then prepared and draped in normal sterile fashion in dorsal lithotomy position. Large clots removed from ruptured vulvar hematoma, suction and retractors were used to explore the bledding hematoma. Used vicryl 3-0 to take severa stiches to try to control the bleeding. Asked Dr for an intra op consult and she agreed to continue to close the blind space. Bleeding noted from an area right next to the foley. Switched the foley to a bigger one so the urethra could be better evaluated. Asked for Urologist for an intra op consult since the bleeding was noted to be next to the urethra. While Dr was in route the hematoma was packed and pressure held. He scrubed in and placed several stiches and bleeding controlled in the area. Several areas noted to be oozing, powedered cergicel used and pressure was held for several minutes. The area finally looked more hemostatic. Used chromic 2-0 to close the blind space and closed the hematoma opening. Urine noted to be clear and flowing in the foley well. Procedure ended well. Patient will be taken to ICU.
PREOPERATIVE DIAGNOSES:
1. Vulvar hematoma, ruptured
POSTOPERATIVE DIAGNOSES: Same as above
NAME OF PROCEDURE: exploration of ruptured vulvar hematoma
ANESTHESIA: GETA
ESTIMATED BLOOD LOSS: 1000 cc
FINDINGS: 5cm depth by 3cm width, extension superiorly to mons pubis
COMPLICATIONS: None.
DRAINS: Foley catheter.
SPECIMENS: none
COUNTS: Correct x3.
DVT PROPHYLAXIS: SCDs in place and the onset of the case
PREOPERATIVE ANTIBIOTICS: Ancef 1 grams
DESCRIPTION OF PROCEDURE: The patient was taken back to the operating room where patient was appropriately anesthetized with the GETA anesthesia. A timeout was then performed verifying the correct patient, the correct procedure, and the correct diagnosis. Once everyone in the room was in agreement the procedure was started. The patient was then prepared and draped in normal sterile fashion in dorsal lithotomy position. Large clots removed from ruptured vulvar hematoma, suction and retractors were used to explore the bledding hematoma. Used vicryl 3-0 to take severa stiches to try to control the bleeding. Asked Dr for an intra op consult and she agreed to continue to close the blind space. Bleeding noted from an area right next to the foley. Switched the foley to a bigger one so the urethra could be better evaluated. Asked for Urologist for an intra op consult since the bleeding was noted to be next to the urethra. While Dr was in route the hematoma was packed and pressure held. He scrubed in and placed several stiches and bleeding controlled in the area. Several areas noted to be oozing, powedered cergicel used and pressure was held for several minutes. The area finally looked more hemostatic. Used chromic 2-0 to close the blind space and closed the hematoma opening. Urine noted to be clear and flowing in the foley well. Procedure ended well. Patient will be taken to ICU.
