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1.) PREOPERATIVE DIAGNOSIS: Lesion of vocal cords.
POSTOPERATIVE DIAGNOSIS: Tumor of left vocal cord

The patient is a 25-year-old student of opera who presented with a lesion of her left vocal cord seen on office laryngoscopy. Today she is seen in the ambulatory suite for further examination of this lesion, using the operating microscope. After the administration of local anesthesia, a direct endoscope is introduced. The operating microscope is brought into the field, and the pharynx and larynx are visualized.

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The pharynx appears normal. There was a mass noted of the left vocal cord. The mass was approximately 2.0cm in size and was removed in total and sent to pathology for analysis. All secretions were suctioned, and the area was irrigated with saline. The patient had minimal blood loss. It should be noted that the pathology report stated benign tumor of the vocal cord

CPT CODE: __________________________

ICD-9-CM CODE: _____________________

POSTOPERATIVE DIAGNOSIS:Mucosal lesion of bronchus.
The bronchoscopy was passed through the nose. The vocal cords were identified and appeared normal. No lesions were seen in this area. The larynx and trachea were then identified and also appeared normal with no lesions or bleeding. The main carina was sharp. All bronchial segments were visualized. There was an endobronchial mucosal lesion. This was located on the right lower lobe of the bronchus. The lesion was occluding the right lower lobe of the bronchus. No other lesions were seen. With use of fluoroscopic guidance, transbronchial biopsies were taken of the area of the lesion. Brush washings were also done for cytology analysis. The patient tolerated both procedures well and was sent to the recovery area in stable condition.

CPT CODE(S): ________________________________

MODIFIER: _________________________

POSTOPERATIVE DIAGNOSIS: Carcinoma of the right lung.

OPERATION PERFORMED: Bronchoscopy and right upper lobectomy. The patient was brought into the operating room; and after the administration of anesthesia, the patient was prepped and draped in the usual sterile fashion. The patient was placed in the left lateral decubitus position. A thoracotomy incision was made. This exposed the chest muscles, which were incised and retracted. The fourth and fifth ribs were visualized and transected to allow entrance to the chest. A tumor mass was noted involving the right lung upper lobe.

The right upper lobe was then removed. Saline was irrigated into the chest. It was noted that the liver and diaphragm appeared to be normal with no lesions seen. After verification that the sponge count was correct, chest tubes were placed for drainage. The surgical wound was closed in layers with chromic catgut and nylon. The patient tolerated this portion of the procedure well. The patient was then placed in the supine position for the bronchoscopy. The patient was still under anesthesia. A flexible fiberoptic bronchoscope was inserted. Patent bronchi were noted bilaterally. The scope was withdrawn. The patient was awakened and sent to the recovery are in stable condition.

ICD-9 CODE: ____________________________________________

7.) PREOPERATIVE DIAGNOSIS: Acute respiratory insufficiency due to ALS. POSTOPERATIVE DIAGNOSIS: Acute respiratory insufficiency due to ALS .OPERATION PERFORMED: Tracheostomy.
The patient, a 45-year-old male with ALS, has been experiencing severe shortness of breath of a progressive nature over the last several weeks. After discussion of all risks, the decision has been made to perform a tracheostomy on this patient. The patient was brought into the operating suite for this procedure and placed supine on the table. General anesthesia was given, and the patient was prepped and draped in the usual sterile fashion.

A 2.5cm incision was made of the neck over the trachea. The trachea was carefully isolated from the surrounding structures after the tracheal rings were identified. The second ring was identified, and a tube was advanced after incision. The patient’s breath sounds were checked and were adequate. The tracheostoma was packed with gauze, and the ties were secured. A chest x-ray will be donepostoperatively to check for tube placement, but breath sounds were good when the patient went to the recovery room.

CPT SERVICE CODE: ____________________________________

ICD-9-CM DX CODE(S): __________________________________________

9.) LOCATION: Outpatient. Hospital
PATIENT:Liz Charles
PHYSICIAN:Gregory Dawson. MD
STUDY PERFORMED BY PHYSICIAN ONLY:Nocturnal polysomnogram without CPAP titration ENTRANCE DIAGNOSIS: Somnolence
This is a fully attended, multichannel nocturnal polysomnogram, giving the patient 386.6 minutes in bed, 317 minutes asleep with 61 arousals through the night which is above the normal. It looks like she had some difficulty with sleep maintenance. She had sleep onset at 18.5 minutes, REM latency 171.5 minutes, again a little bit prolonged. She had 27 respiratory events through the night, a mixture of obstructive apneas and obstructive hypopneas with a respiratory disturbance index of 5.1. Anything over 5 is considered significant. The longest duration of anyone event was 34 seconds. O2 sat was between 76 and 95%, with 29% of the time spent with O2 sats less than 88%.

Heart rate varied between 55 and 113, somewhat varying with the obstructive events. The patient had grade 1-2 snoring noted, and respiratory disturbance events were most evident in REM while supine. All five stages of sleep were represented. Basically the only thing abnormal was a reduced amount of REM. OVERALL IMPRESSION: This patient has significant obstructive sleep apnea based on the respiratory disturbance index of 5.1. Which anything over 5 is considered significant, plus the amount of time that the patient spent hypoxic, at less than 88%.29% of the time was spent that way. So I suspect that the patient does have significant obstructive sleep apnea. We will need a second sitting to do the CPAP titration. The overall impression is obstructive sleep apnea.

CPT SERVICE CODE and MODIFIER: ________________________

ICD·9·CM DXCODE(S): ____________________________________

10.) LOCATION: Inpatient, Hospital
PATIENT: Russell Shergrud
PREPROCEDURE DIAGNOSIS: Acute respiratory failure
POSTPROCEDURE DIAGNOSIS: Acute respiratory failure
PROCEDURE PERFORMED: Intubation with a #8 endotracheal tube
The first attempt was with an 8.5 endotracheal tube, which just did not fit in the vocal cords. I was afraid of causing trauma, so we switched to a #8 endotracheal tube, which went in nicely. He had good return on the capnograph, and we eventually got O2 (oxygen) saturations up to 90%. It took 35 minutes to do that, to get his O2 stats back up from about 60% to over 90% once he was intubated. I got here toward the middle of the respiratory arrest, so I do not think any sedation was given. A chest x-ray will be taken postprocedure to assure ourselves of a good placement.

CPT SERVICE CODE: ___________________________________________________ ICD-9-CM DX CODE: _______________________________________________


PREOPERATIVE DIAGNOSIS. (2016, May 30). Retrieved from https://graduateway.com/preoperative-diagnosis/

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