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Can any one assist with this op note?

  1. #1
    Post Can any one assist with this op note?
    Medical Coding Books
    PREOPERATIVE DIAGNOSIS: Emphysema with blebs and bullae with
    spontaneous pneumothorax.

    POSTOPERATIVE DIAGNOSIS: Emphysema with blebs and bullae with
    spontaneous pneumothorax.

    1. Right thoracotomy.
    2. Wedge resection of multiple blebs and bullae.
    3. Repair and resection of apical infected bullae.




    ANESTHESIA: General endotracheal tube with a double-lumen tube.


    FLUIDS: 2 liters.

    DRAINS/TUBES: Foley catheter was left in place, as well as 2 chest
    tubes in the right chest.



    OPERATIVE FINDING: Infected, dense adhesions to the apical bleb with
    evidence of recent infection, multiple bullae and blebs, wedge
    resections, and emphysematous lungs. Specimens were sent to pathology.

    DESCRIPTION OF PROCEDURE: The patient was taken to the operating room,
    and prepped and draped in the standard fashion for a right thoracotomy.
    A right thoracotomy, more anterolateral, was made entering into the
    fifth interspace. Rib spreader was put into place, and the chest was
    examined. There were dense adhesions to the apex with multiple large
    bullae. Dissection was carried out extrapleural in that region. There
    were blebs in the middle lobe along the lower edge, as well as some in
    the lower lobe and the upper lobe throughout the lung, and clear
    emphysematous changes throughout the lung as well. Water was placed
    into the chest cavity, and 30 mmHg pressure was held. There were some
    bubbles coming from what appeared to be the lower lobe. It was
    difficult to locate the exact location. There was a minimal amount of
    air leak from the apical bleb. Wedge resections were done of multiple
    locations on the right lower lobe in the superior segment, the right
    middle lobe along the lower edge, as well as the right upper lobe along
    the edge of the anterior portion. The infected bleb that was in the
    apex that was densely adhered to the chest wall was partially resected
    and then sewn with a 2-0 Vicryl for repair of the apex of the lung. It
    was too involved and too dense to be able to do a wedge resection of
    that portion of the lung. Once this was complete, water was placed
    into the chest cavity, once again putting 30 mmHg. There was a small
    amount of air coming from one of the wedge resection stable lines,
    otherwise relatively free from any air leaks. Two chest tubes were put
    into place, 1 anterior and 1 posterior. Pericardial sutures were
    placed around the ribs. Of note, the fifth rib was cracked in the
    midline of the rib. The mechanical pleurodesis of the chest wall was
    performed following by talc being placed within the chest cavity. The
    chest was then closed, and ribs were reapproximated, followed by
    closure of each of the muscle layers, serratus and latissimus; deep
    dermal and skin layer was also performed. Dermabond was used to seal
    the incision. The patient had 2 chest tubes prior to coming to the OR.
    Those had been removed prior to starting the case, and an occlusive
    dressing was placed over those 2 holes. The patient was transported to
    the PACU where he is expected to recover and then be admitted to the
    Last edited by EMS7775; 07-01-2009 at 11:52 AM.

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