slc112071
Networker
Could someone please help me with the CPT coding on the following report? I am having problems finding the correct codes.
Thank you in advance.
PREOPERATIVE DIAGNOSIS:
1. Cardiac tamponade, pericardial effusion /hemopericardium.
2. Cardiogenic shock.
3. Coronary artery disease status post coronary bypass grafting.
4. Left pleural effusion.
POSTOPERATIVE DIAGNOSES:
1. Cardiac tamponade, pericardial effusion /hemopericardium.
2. Cardiogenic shock.
3. Coronary artery disease status post coronary bypass grafting.
4. Left pleural effusion.
PROCEDURE PERFORMED:
1. Subxiphoid pericardial window/mediastinal reexploration.
2. Left chest tube insertion.
HISTORY OF PRESENT ILLNESS: The patient is a 61-year-old male who underwent
coronary bypass grafting two weeks ago. He appears anticoagulated for atrial
fibrillation. The patient developed a hemopericardium and is in tamponade
with cardiogenic shock. The patient to the OR for emergency reexploration.
OPERATIVE FINDINGS: The patient had a clotted hemopericardium, some free
flowing blood, but a lot of it was just clot. Mostly it was down on top of
the diaphragm and behind the left ventricle.
OPERATIVE NOTE: The patient was brought in the OR, placed on the table in
supine position. Appropriate monitoring devices were placed. He was
intubated emergently. Femoral art line and central venous line were placed.
He was quickly prepped and draped. The old incision was opened up down by the
xiphoid. We opened it up, we had some bloody fluid coming out of the
pericardium. We carefully evacuated clot down off on top of the diaphragm.
This is where most it seemed to be located. Much of it was clot and had to be
carefully removed. There was a vein graft down in the PDA and this area also
had to be carefully avoided. There was not much clot up between the RV and the
chest wall. I cannot find much clot out by the right atrium. I also used a
30 degree 5 mm scope to help me to see. I did not open the sternum or remove
the wires. Once I was satisfied with removal of the clot, I placed two Blake
drains, one over the diaphragm and one anteriorly. We irrigated out with a
copious amount of warm saline. A left pleural chest tube was then placed at
about the seventh interspace in the mid axillary line. This returned some
blood tinged fluid. We then closed the wound with a #1 Vicryl for the muscle
layer, 2-0 Vicryl subcutaneous tissue and Monocryl for the skin. Dressing was
applied. The patient was unstable at the beginning of the case but seemed to
have improved by the end. At the beginning of the surgery, he was on
high-dose dopamine and also started bleeding and started on neosynepherine.
At the end, he was on 2 mcg of epinephrine only. Blood loss from the actual
surgery was minimal. No specimen was sent.
Thank you in advance.
PREOPERATIVE DIAGNOSIS:
1. Cardiac tamponade, pericardial effusion /hemopericardium.
2. Cardiogenic shock.
3. Coronary artery disease status post coronary bypass grafting.
4. Left pleural effusion.
POSTOPERATIVE DIAGNOSES:
1. Cardiac tamponade, pericardial effusion /hemopericardium.
2. Cardiogenic shock.
3. Coronary artery disease status post coronary bypass grafting.
4. Left pleural effusion.
PROCEDURE PERFORMED:
1. Subxiphoid pericardial window/mediastinal reexploration.
2. Left chest tube insertion.
HISTORY OF PRESENT ILLNESS: The patient is a 61-year-old male who underwent
coronary bypass grafting two weeks ago. He appears anticoagulated for atrial
fibrillation. The patient developed a hemopericardium and is in tamponade
with cardiogenic shock. The patient to the OR for emergency reexploration.
OPERATIVE FINDINGS: The patient had a clotted hemopericardium, some free
flowing blood, but a lot of it was just clot. Mostly it was down on top of
the diaphragm and behind the left ventricle.
OPERATIVE NOTE: The patient was brought in the OR, placed on the table in
supine position. Appropriate monitoring devices were placed. He was
intubated emergently. Femoral art line and central venous line were placed.
He was quickly prepped and draped. The old incision was opened up down by the
xiphoid. We opened it up, we had some bloody fluid coming out of the
pericardium. We carefully evacuated clot down off on top of the diaphragm.
This is where most it seemed to be located. Much of it was clot and had to be
carefully removed. There was a vein graft down in the PDA and this area also
had to be carefully avoided. There was not much clot up between the RV and the
chest wall. I cannot find much clot out by the right atrium. I also used a
30 degree 5 mm scope to help me to see. I did not open the sternum or remove
the wires. Once I was satisfied with removal of the clot, I placed two Blake
drains, one over the diaphragm and one anteriorly. We irrigated out with a
copious amount of warm saline. A left pleural chest tube was then placed at
about the seventh interspace in the mid axillary line. This returned some
blood tinged fluid. We then closed the wound with a #1 Vicryl for the muscle
layer, 2-0 Vicryl subcutaneous tissue and Monocryl for the skin. Dressing was
applied. The patient was unstable at the beginning of the case but seemed to
have improved by the end. At the beginning of the surgery, he was on
high-dose dopamine and also started bleeding and started on neosynepherine.
At the end, he was on 2 mcg of epinephrine only. Blood loss from the actual
surgery was minimal. No specimen was sent.