rlohearn
Contributor
Any and all help appreciated with this one:
PREOPERATIVE DIAGNOSIS: Status post decompression, left shoulder with
attenuation of deltoid attachment.
POSTOPERATIVE DIAGNOSES:
1. Marked hypertrophic subacromial bursitis.
2. Attenuation of anterior deltoid attachment.
OPERATION: Exploration of the shoulder with excision of hypertrophic bursa
and reefing of deltoid muscle attachment.
ASSISTANT: None.
PROCEDURE: Under satisfactory general anesthesia the patient was placed in a
semi-sitting position with the shoulder table. All extremities were well
padded. The left shoulder was prepped and draped in the usual manner. I
outlined the skin incision with about 5 mls of 1/2% Marcaine with epinephrine
1:200,000 to help with hemostasis. The skin incision was made through the
previous scar from just proximal to the AC joint distally for about three
inches. By sharp and blunt dissection I exposed the fascia overlying the
deltoid. All sutures were removed. I was able to feel almost like a weak
area proximally where the deltoid normally would have attached to the
acromion. I split the deltoid in the direction of its fibers for about 1 1/2
inches and then detached this near the anterior acromion leaving a cuff of
tissue for reattachment at the conclusion of the procedure. This was quite
thickened scar-type tissue. I excised a portion of this. The most striking
finding was significant hypertrophic bursa that was in the subacromial space.
This was almost scar-like. Using Metzenbaum I was able to dissect the
majority of this out. The cuff itself appeared to be intact. No
abnormalities were noted of this. After excision of this bursa I went ahead
and reattached the deltoid with numerous #1 Ethibond sutures reefing this up
proximally. The ________________ was also closed with #1 Ethibond.
Subcutaneous tissue was closed with 2-0 Vicryl and skin with wire staples.
Dry dressings were applied along with a sling and swath. Sponge and
instrument count were correct. Estimated blood loss was approximately 30
mls. Patient tolerated the procedure well, left the operating room in
satisfactory condition.
We have 24341 for the deltoid "reefing", but can't settle on something for the bursectomy. We considered 23107, but the note doesn't quite seem to support that. If we must go unlisted, so be it--but I'd love to get some expert advice before going that route. Thanks in advance!!!
PREOPERATIVE DIAGNOSIS: Status post decompression, left shoulder with
attenuation of deltoid attachment.
POSTOPERATIVE DIAGNOSES:
1. Marked hypertrophic subacromial bursitis.
2. Attenuation of anterior deltoid attachment.
OPERATION: Exploration of the shoulder with excision of hypertrophic bursa
and reefing of deltoid muscle attachment.
ASSISTANT: None.
PROCEDURE: Under satisfactory general anesthesia the patient was placed in a
semi-sitting position with the shoulder table. All extremities were well
padded. The left shoulder was prepped and draped in the usual manner. I
outlined the skin incision with about 5 mls of 1/2% Marcaine with epinephrine
1:200,000 to help with hemostasis. The skin incision was made through the
previous scar from just proximal to the AC joint distally for about three
inches. By sharp and blunt dissection I exposed the fascia overlying the
deltoid. All sutures were removed. I was able to feel almost like a weak
area proximally where the deltoid normally would have attached to the
acromion. I split the deltoid in the direction of its fibers for about 1 1/2
inches and then detached this near the anterior acromion leaving a cuff of
tissue for reattachment at the conclusion of the procedure. This was quite
thickened scar-type tissue. I excised a portion of this. The most striking
finding was significant hypertrophic bursa that was in the subacromial space.
This was almost scar-like. Using Metzenbaum I was able to dissect the
majority of this out. The cuff itself appeared to be intact. No
abnormalities were noted of this. After excision of this bursa I went ahead
and reattached the deltoid with numerous #1 Ethibond sutures reefing this up
proximally. The ________________ was also closed with #1 Ethibond.
Subcutaneous tissue was closed with 2-0 Vicryl and skin with wire staples.
Dry dressings were applied along with a sling and swath. Sponge and
instrument count were correct. Estimated blood loss was approximately 30
mls. Patient tolerated the procedure well, left the operating room in
satisfactory condition.
We have 24341 for the deltoid "reefing", but can't settle on something for the bursectomy. We considered 23107, but the note doesn't quite seem to support that. If we must go unlisted, so be it--but I'd love to get some expert advice before going that route. Thanks in advance!!!