cpccoder2008
True Blue
Can someone please help me with this op report. Thanks
PREOPERATIVE DIAGNOSIS: Missed abortion versus ectopic pregnancy.
POSTOPERATIVE DIAGNOSIS: Right ectopic pregnancy.
OPERATIONS:
1. Dilatation and curettage.
2. Diagnostic scope.
3. Lysis of adhesion.
4. Bilateral salpingectomy.
ANESTHESIA: General.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: 50 mL.
FLUIDS: 2000 mL.
URINE OUTPUT: 150 mL clear urine noted at the end of the procedure.
SPECIMEN: Uterus and left tube were sent to pathology as well as endometrial curettings.
OPERATIVE FINDINGS: D and C findings, the uterus sounded to 10 cm and it was dilated to 7 cm with Hegar dilator and moderate amount of tissue was removed with the curettage and sent to frozen, pathology, which resulted in no chorionic villi with this endometrium.
OPERATIVE FINDINGS ON DIAGNOSTIC LAPAROSCOPY: There was severe adhesive disease noted in the omentum to the anterior abdominal wall and from the left ovary to the left tube. The left tube was grossly normal with the exception of adhesions noted above and ectopic pregnancy was then identified about 2 x 1 cm in the ampullary region and normal right ovary. In the left ovary, there was a simple cyst noted 2 x 1 cm, and there was a small amount of blood in the cul-de-sac noted and the uterus was noted to be normal.
PROCEDURE IN DETAIL: The patient was taken to the operating room, where general anesthesia was obtained without difficulty. She was placed in dorsal lithotomy position and prepped and draped in the normal sterile fashion. A Foley catheter was placed in the bladder. A weighted speculum was placed into the vagina. A right angle was used to visualize the cervix and the anterior lip of the cervix was grasped with a single tooth tenaculum. The uterus was then sounded to 10 cm was anteriorly and dilated to maximum with 7 Hegar dilator. Endometrial curettage was then performed and mild amount of tissue was obtained. At this time, the uterine manipulator was placed into the cervix and the single tooth tenaculum as well as the weighted speculum was removed. The patient's abdomen was then prepped and redraped and the surgeons then rescoped, re-gowned and gloved. At this time, towel clamps were used to grasp the infraumbilical fold and was elevated and tented up. A Veress needle was then placed into the anterior abdominal cavity after two clicks were heard. Anterior abdominal placement was confirmed by water drop test as well as low intraabdominal pressure. Once this was confirmed, the abdomen was insufflated to maximum of 15 mmHg of insufflation. The trocar was then placed into the abdominal cavity. A camera was placed into the cavity and the abdominal cavity was visualized. At that time, there was adhesive disease noted with the omentum to the anterior abdominal wall. Rest of the anatomy scan was performed. At this time, decision was made to take down adhesions. Adhesions were taken down with the use of EndoShears through clear filmy areas. Once this has been performed, an incision was made in the right lower quadrant. A Veress needle was placed in the trocar. A 5-mm trocar was placed under direct visualization. Decision was made to place the trocar in the central abdominal region. Again, under direct visualization, moderate amount of adhesions were then removed. A left lower quadrant port was placed once again under direct visualization. Port placement had been made. The tubes were further inspected and there was noted to be an ectopic pregnancy in the right tube. This was removed using the Everest. Once the tube was removed, it was placed in the EndoCatch bag and removed from the abdomen. The right tube was then removed using the Everest. Excellent hemostasis was noted. Attention was then turned to the left tube, which was noted to be adhesed to the left ovary. A left ovarian simple cyst was noted. At this time, the left tube was removed with the Everest. Once removal had been performed, Everest was removed from the abdomen. Excellent hemostasis was noted in this area as well. Suction and irrigation was performed to remove minimal amount of blood that was noted in the cul-de-sac. Once suction and irrigation was performed, again scan of the pelvic anatomy was performed. Excellent hemostasis was noted. The trocars were removed under direct visualization. Electrocautery was used for hemostasis. The incisions were closed with 4-0 Monocryl. Sponge, lap, and needle counts were correct x2. The patient was transferred to recovery room in stable condition and she will be discharged home with ambulating, voiding, and tolerating p.o. without difficulty. She is been instructed to follow up in six weeks. She is been given strict bleeding, pain, and fever precautions. She is been instructed on pelvic rest x6 weeks. She is being discharged home with prescription for Anaprox, Vicodin, as well as Macrobid for UTI that was diagnosed at the time of admit.
I'm coming up with 58120, 49320, 49329 and 59120
PREOPERATIVE DIAGNOSIS: Missed abortion versus ectopic pregnancy.
POSTOPERATIVE DIAGNOSIS: Right ectopic pregnancy.
OPERATIONS:
1. Dilatation and curettage.
2. Diagnostic scope.
3. Lysis of adhesion.
4. Bilateral salpingectomy.
ANESTHESIA: General.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: 50 mL.
FLUIDS: 2000 mL.
URINE OUTPUT: 150 mL clear urine noted at the end of the procedure.
SPECIMEN: Uterus and left tube were sent to pathology as well as endometrial curettings.
OPERATIVE FINDINGS: D and C findings, the uterus sounded to 10 cm and it was dilated to 7 cm with Hegar dilator and moderate amount of tissue was removed with the curettage and sent to frozen, pathology, which resulted in no chorionic villi with this endometrium.
OPERATIVE FINDINGS ON DIAGNOSTIC LAPAROSCOPY: There was severe adhesive disease noted in the omentum to the anterior abdominal wall and from the left ovary to the left tube. The left tube was grossly normal with the exception of adhesions noted above and ectopic pregnancy was then identified about 2 x 1 cm in the ampullary region and normal right ovary. In the left ovary, there was a simple cyst noted 2 x 1 cm, and there was a small amount of blood in the cul-de-sac noted and the uterus was noted to be normal.
PROCEDURE IN DETAIL: The patient was taken to the operating room, where general anesthesia was obtained without difficulty. She was placed in dorsal lithotomy position and prepped and draped in the normal sterile fashion. A Foley catheter was placed in the bladder. A weighted speculum was placed into the vagina. A right angle was used to visualize the cervix and the anterior lip of the cervix was grasped with a single tooth tenaculum. The uterus was then sounded to 10 cm was anteriorly and dilated to maximum with 7 Hegar dilator. Endometrial curettage was then performed and mild amount of tissue was obtained. At this time, the uterine manipulator was placed into the cervix and the single tooth tenaculum as well as the weighted speculum was removed. The patient's abdomen was then prepped and redraped and the surgeons then rescoped, re-gowned and gloved. At this time, towel clamps were used to grasp the infraumbilical fold and was elevated and tented up. A Veress needle was then placed into the anterior abdominal cavity after two clicks were heard. Anterior abdominal placement was confirmed by water drop test as well as low intraabdominal pressure. Once this was confirmed, the abdomen was insufflated to maximum of 15 mmHg of insufflation. The trocar was then placed into the abdominal cavity. A camera was placed into the cavity and the abdominal cavity was visualized. At that time, there was adhesive disease noted with the omentum to the anterior abdominal wall. Rest of the anatomy scan was performed. At this time, decision was made to take down adhesions. Adhesions were taken down with the use of EndoShears through clear filmy areas. Once this has been performed, an incision was made in the right lower quadrant. A Veress needle was placed in the trocar. A 5-mm trocar was placed under direct visualization. Decision was made to place the trocar in the central abdominal region. Again, under direct visualization, moderate amount of adhesions were then removed. A left lower quadrant port was placed once again under direct visualization. Port placement had been made. The tubes were further inspected and there was noted to be an ectopic pregnancy in the right tube. This was removed using the Everest. Once the tube was removed, it was placed in the EndoCatch bag and removed from the abdomen. The right tube was then removed using the Everest. Excellent hemostasis was noted. Attention was then turned to the left tube, which was noted to be adhesed to the left ovary. A left ovarian simple cyst was noted. At this time, the left tube was removed with the Everest. Once removal had been performed, Everest was removed from the abdomen. Excellent hemostasis was noted in this area as well. Suction and irrigation was performed to remove minimal amount of blood that was noted in the cul-de-sac. Once suction and irrigation was performed, again scan of the pelvic anatomy was performed. Excellent hemostasis was noted. The trocars were removed under direct visualization. Electrocautery was used for hemostasis. The incisions were closed with 4-0 Monocryl. Sponge, lap, and needle counts were correct x2. The patient was transferred to recovery room in stable condition and she will be discharged home with ambulating, voiding, and tolerating p.o. without difficulty. She is been instructed to follow up in six weeks. She is been given strict bleeding, pain, and fever precautions. She is been instructed on pelvic rest x6 weeks. She is being discharged home with prescription for Anaprox, Vicodin, as well as Macrobid for UTI that was diagnosed at the time of admit.
I'm coming up with 58120, 49320, 49329 and 59120