Cases Flashcards by Kristin Burns

Preoperative Diagnosis:
Malunion, Radius/Ulna
Postoperative Diagnosis:
Same
Procedure(s) Performed:
Repair, Nonunion, Radius/Ulna,
Right
A 10-year-old sustained a both-bone right forearm fracture recently treated previously with reduction and casting, however, has gone to malposition. Cast was removed, and obvious deformity was identified.
Closed reduction was able to be obtained, and then a 1 cm incision was made over the area of Lister’s tubercle, just proximal to the growth plate, where a 2.0 mm titanium rod into the intermedullary canal was passed and placed.

25415-RT

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OPERATIVE REPORT
Preoperative Diagnosis:
Senile Cataract, right eye
Postoperative Diagnosis:
Same
Procedure (s)
Performed:
Extraction, right eye
Cataract
An extracapsular cataract removal is performed on the right eye by manually using an iris expansion device to expand the pupil. A phacoemulsification unit was used to remove the nucleus, and irrigation and aspiration were used to remove the residual cortex, allowing the insertion of the intraocular lens.

66982-RT

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Preoperative Diagnosis:
neck infection.
Bladder
Post operative Diagnosis:
Same
Procedure(s) Performed:
Incision of bladder neck infection
After the patient was prepped and draped in the lithotomy position, using the resectoscope, the urethra and bladder were inspected. He had about a ten French bladder neck contraction.
Guidewire was inserted through the contraction, and then using the Collins knife cutting at the two, ten, seven, and five o’clock positions, the bladder neck was opened. Electrical cautery was used to obtain hemostasis.
Patient tolerated procedure well.

52500

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Preoperative Diagnosis:
Lateral meniscus tear
Postoperative Diagnosis:
Lateral meniscus tear,
chondromalacia medial/lateral patella, chondral injury medial femoral condyle
Procedure(s) Performed:
Scope revealed extensive Grade III chondromalacia of the right medial and lateral patella, which was debrided with a full-radial shaver and chondroplasty completed. The right medial and lateral compartments were entered with the scope revealing a medial and lateral meniscus tear that was resected with a full-radial shaver. There was also a full-thickness chondral injury to the medial femoral condyle, and a large chondral flap was also resected. A microfracture was also performed on the medial femoral condyle.

29880-RT, 29879-51-RT

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Preoperative Diagnosis:
right nose BCC
Procedure(s) Performed:
Excision BCC, tissue transfer
Excision of a basal cell carcinoma of the right nose and reconstruction with an
advancement flap. The 1.2 cm lesion with an excised diameter of 1.5 cm was excised with a 15-blade scalpel down to the level of the subcutaneous tissue, totaling a primary defect of 1.8 cm.
Electrocautery was used for hemostasis. An adjacent tissue transfer of 3 sq cm was taken from the nasolabial fold and was advanced into the primary defect.

14060, C44.311

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Subluxation, 2nd metatarsophalangeal joint, right foot
Hammer toe deformity, 2nd toe, right foot
Same
Osteoplasty, 2nd metatarsal head, right foot
Arthroplasty proximal interphalangeal joint,
2nd toe, right foot

A dorsolongitudinal skin incision, approximately 4 cm in length, was made extending from mid shaft of the 2nd metatarsal proximally to the base of the proximal phalanx of the 2nd toe distally. The skin and subcutaneous tissues were underscored and retracted. The incision was then deepened medial to the extensor digital and longus tendon and carried down to the level of the metatarsal head. The capsular and ligamentous structures then separated from the 2nd
metatarsal head, and the 2nd toe plantar flexed, thereby bringing the 2nd metatarsal head into view. Utilizing a power saw and beginning at the surgical neck of the metatarsal head, a cut was made perpendicular to the shaft approximately one half the width of the metatarsal head and then beveled at a 45-degree angle to include the plantar condyles. The severed bone was then dissected out by sharp dissection, and all rough edges were rasped smooth.
The right foot was loaded, finding good release of subluxation occurring at the level of the 2nd metatarsophalangeal joint but with considerable contractures still occurring at the proximal phalangeal joint of the 2nd toe.
Therefore, two longitudinal ellipsing skin incisions were made directly over the head of the proximal phalanx of the 2nd toe.
The created skin wedge was then sharply dissected. The skin and subcutaneous tissues were underscored and retracted. A transverse incision was then made through the capsule and extensor tendon complex at the proximal interphalangeal joint.
The medial and lateral collateral ligaments were incised, and the head of the proximal phalanx was delivered. Utilizing a power saw, the head of the proximal phalanx was then resected, and all bony edges were rasped smooth. At the level of the 2nd
metatarsophalangeal joint, the ligamentous and capsular structures were repaired with interrupted sutures of 2-0 Vicryl.
Superficial tissues were then closed with 3-0 Vicryl, and the skin margins were approximated with interrupted horizontal mattress sutures of 4-0 nylon.
Attention was then directed to the 2nd toe, where the extensor tendon and collateral ligaments were repaired with interrupted sutures of 3-0 Vicryl. Skin margins were then approximated with interrupted horizontal mattress sutures of 4-0 nylon.
Before bandaging, the right foot margins were then approximated with interrupted horizontal mattress sutures of 4-0 nylon.
Before bandaging, the right foot was again loaded, finding a normally positioned 2nd toe.

28285-T6

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Preoperative
Diagnosis:
1. Grade 2
2. closed
3. fracture of left distal radius and ulnar shafts
4. Fracture of left radial head
Post operative
Diagnosis:
Same
Procedure(s)
Performed:
1. Closed reduction of radial and ulnar shafts, left
2. Closed reduction of radial and ulnar shafts, left
3. Application of short arm cast

INDICATIONS FOR OPERATION:
This 7-year-old young man fell out of a box on the back of a 4-wheeler. X-rays revealed a radial shaft and ulnar shaft fracture on the left. Traction was applied, and the fractures were manipulated into satisfactory alignment with good reduction of both the ulnar and radial shaft fractures. A short arm cast was applied to the affected area.

25565

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Preoperative Diagnosis:
Traumatic scalp wound w/bone exposure
Postoperative Diagnosis:
Same
Procedure(s) Performed:
Debridement/Irrigation Traumatic
Scalp Wound with flap coverage
INDICATION FOR SURGERY: The patient is a 70-year-old female who fell from a concrete wall.
She suffered a traumatic injury to her scalp with bone exposure, excessive bleeding, and had a foreign body within the scalp tissue. She did not seek medical attention initially but presented to the emergency room with an infected wound several days later. The wound measured
approximately 10 cm x 4 cm in greatest dimensions. Skin hooks were used to retract the wound edges, and debridement was performed to tissue and fascia.
Fibrinous material and other necrotic tissue were debrided with a curet. Subcutaneous tissue, muscle, and fascia were all thoroughly debrided and cleaned, and the scalp was extensively undermined circumferentially. The wound was pulled together; however, it was not able to cover the area of bone exposure, thus a flap was constructed by incising the scalp over the left temporal area to allow for a rotation of the 40 sq cm flap into the central portion of the wound to cover the exposed bone. The wound edges were reapproximated with interrupted O Vicryl sutures.

14301

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Preoperative Diagnosis:
Change in weight
Postoperative Diagnosis:
Possible celiac disease
Procedure(s) Performed:
EGD
Diagnostic EGD, with biopsies × 3

43239

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Preoperative
Diagnosis:
Tenosynovitis,
left extensor pollicis longus tendon
Post operative
Diagnosis:
Tenosynovitis,
left extensor pollicis longus tendon
Procedure(s) Extensor pollicis
Performed:
longus tenosynovectomy

The patient was brought to the main operating room and positioned supine. The left upper extremity was prepped and draped in the usual fashion. A linear longitudinal incision was made along the course of the extensor pollicis longus tendon, and subcutaneous tissue was carefully spread. A small retractor was placed. I then opened the sheath of the EPL, noting a mildly proliferative ganglion cyst in this location. It did not appear to be grossly pathologic, such as seen with rheumatoid arthritis. It was carefully peeled off of the tendon with small tenotomy scissors. The tourniquet was inflated during this portion of the procedure for better visualization. The tendon itself underlying it was in excellent condition. I then closed the subcutaneous tissue with 2-0
Vicryl sutures and completed with small tenotomy scissors. The tourniquet was inflated during this portion of the procedure for better visualization. The tendon itself underlying it was in excellent condition. I then closed the subcutaneous tissue with 2-0
Vicryl sutures and completed closure with 4-0 nylon. A sterile compression bandage was applied. The tourniquet was deflated.

25111-LT

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Preoperative Diagnosis:
Lesions back, face and arm
Postoperative Diagnosis:
Lesions, back, face and arm
Procedure(s) Performed:
Excision of lesions
Excision of a 2 cm lesion on the lower back with 0.5 cm margins with simple repair. Another lesion was excised from the face, 0.5 cm. Two additional lesions on the arm; both lesions, approximately 1.2 cm, were also excised and closed. Surgical pathology
indicated that the lower back and both arms lesions were malignant.

11603, 11602-51, 11602-
59, 11440-51

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Preoperative Diagnosis:
Patellar entrapment, left
Postoperative Diagnosis:
Patellar entrapment, left
Procedure(s) Performed:
Lateral release, left knee
Arthroscope cannula was
introduced, and the anatomy was examined and appears normal.
There was a tight lateral
retinaculum noted through range of motion of the knee. A longitudinal skin incision was made, incision carried down to the subcutaneous tissue. Nick was made in the lateral patellar retinaculum and lateral patellar release was accomplished.
Arthroscopic portal as well as the lateral release incision was closed.

27425-LT

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Chief Complaint: Epistaxis
History:
S: This is a 45-year-old female complaining of epistaxis. She has had it intermittently for a week and a half. It is on the right side today. Diabetes, hypertension, atrial fibrillation, mitral regurgitation, cirrhosis related to alcoholism, coronary artery disease with previous MI, previous CVA, congestive heart failure, and renal insufficiency. Isn’t on any blood thinners other than aspirin.
On numerous medications that are listed.
O: On exam, blood pressure is not bad. Has a little dried scab of blood in the left nostril so I didn’t touch that. On the right side had just some oozing from the septum that looked raw. I did put a little epinephrine on a cotton swab in there, left it on for awhile, and removed it, and I used a little silver nitrate to cauterize that side of the septum.
Diagnosis/Assessment: Anterior epistaxis

30901-RT

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Anesthesia services for phacoemulsification of cataract, on a normally healthy 72-year-old

00142-P1, 99100

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Preoperative Diagnosis:
Breast carcinoma
Postoperative Diagnosis:
Breast carcinoma
Procedure(s) Performed:
Mastectomy, sentinel node biopsy
Two co of Methylene blue dye was injected beneath the areola, and incision was made along the axillary hairline for sentinel node biopsy. An enlarged deep node was identified and excised for biopsy. Next, an incision was made over the left lateral breast lump, and a sharp dissection margin of normal tissue as well as the palpable lump was taken and excised completely. Sentinel node biopsy returned as positive, and complete deep axillary node dissection was performed.

19302-LT, 38900, C50.912

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Preoperative Diagnosis:
Nonunion, IP joint fracture
Postoperative Diagnosis:
Same
Procedure(s) Performed:
Fixation, IP Joint, right small finger
Procedure performed: Repair of right little finger distal
interphalangeal joint nonunion with screw and fixation. Incision was made, full-thickness flaps were developed, and nonunion site was indented. It was cleaned with rongeur and Freer elevator.
Bony surfaces were repaired, and a guide wire was placed across the fusion site. It was then placed with a 26mm screw and overdrilled with a 26 mm mini screw and fixated with plate.

26860-F9

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Traumatic nasoseptal deformity
Septal perforation
Nasal obstruction
Same
Septoplasty utilizing an external columella approach
Repair of nasoseptal perforation

The patient’s nose was prepped with Betadine prep and then draped in a sterile manner. The nose was packed with cotton pledgets soaked with 4% cocaine.
After several minutes, intranasal and external nasal injection of 1% Xylocaine with 1:100,000 units epinephrine was made. Then utilizing the columella incision, the skin and subcutaneous tissue were elevated off the lower lateral cartilages. The soft tissue between the lower lateral cartilage and the medial crura of the lower lateral cartilages was removed. Subsequently, the septum was isolated and bilateral mucoperichondrial and mucoperiosteal flaps were elevated. The cartilaginous septum was then removed in its entirety except for a dorsal strip. Subsequently, the deviated portion of the bony septum, as well as the maxillary crest, was removed. Subsequently, the perforation was closed on both sides with interrupted 4-0 chromic sutures. The septal cartilage that was removed was then shaved to straighten the cartilage out. This was then brought anteriorly between the perforation repair and the lower lateral cartilage to restore nasal tip support. This was secured between the medial crura with 4-O clear nylon sutures.

30520, 30630-51

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Electrocardiogram is performed four times in the same day by the same physician, interpretation and report only

93010-76

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Preoperative Diagnosis:
Breast Mass, Left
Postoperative Diagnosis:
Breast Mass, Left
Procedure(s) Performed:
Excision, Breast Mass, Left
The left breast was prepped and draped in a sterile fashion. An incision from the 3 o’clock position around to the 9 o’clock position on the areolar border on its inferior aspect was made in the skin and extended to the subcutaneous tissue under the previously placed localization wire was located. The breast mass was excised by sharp dissection.
The mass was found to be approximately 1.5-2 cm in maximum dimension.

19125-LT, N63.20

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Preoperative Diagnosis: habits
Change in bowel
Postoperative Diagnosis:
Polyps, Sigmoid Colon
Procedure(s) Performed:
Colonoscopy
Scope was advanced into the cecum. An area that appeared to be a flat lesion was biopsied by hot biopsy forceps. In the sigmoid colon, two polyps were identified and both were biopsied as well.

45380

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Nasal fracture
Deviated nasal septum
Bilateral inferior turbinate hypertrophy
Same
Open reduction of nasal fracture
Septoplasty
Bilateral inferior turbinate reduction

We began by decongesting the nose with 4% cocaine on cottonoids. We then injected both sides of the septum as well as the inferior turbinates and the skin of the nose with 1% lidocaine with epinephrine. We first began the procedure by performing the septoplasty. We used a #15 blade knife to make a left
hemitransfixion incision and elevated the mucoperichondrial flap off of the cartilage and bone of the septum. We removed and/or replaced in the midline the deviated portions of the septum.
We also used a rasp to smooth out the dorsal surface of the nose. After this was completed, we were able to reduce the inferior turbinates by first outfracturing them and then reducing them with the bipolar electrocautery. The bony nasal work was done via
intercartilaginous incisions, which were made between the upper lateral and the lower lateral cartilages of the nose.

30520, 30130-50

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MRI lumbar spine with oral contrast

72148

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Preoperative Diagnosis:
Right lower lobe mass
Postoperative Diagnosis:
CT
guided biopsy of right lower lung mass
Procedure(s) Performed:
guided lung biopsy
CT
The patient was positioned supine, and an appropriate area of puncture was made over the lower portion of the chest. An appropriate area was cleansed and anesthetized with 3 ccs of 1% Xylocaine. An 18-gauge spring-loaded needle was inserted approximately 4 cm to the right of the midline into a 6 x 5 cm mass in the right base medially. Three cores of tissue were removed using the co-axial spring-loaded
18-gauge biopsy needle. No bleeding could be seen in the chest after the study, and there was no pneumothorax identified.
The patient received 1 mg of Versed intravenously for sedation.

32408

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End-stage renal disease; infected Ash catheter, dialysis status
End-stage renal disease; infected Ash catheter
Left femoral Quinton catheter placement

The 22-year-old patient was brought to Ambulatory Care and placed in the supine position; right groin was prepped and draped in sterile fashion. We attempted to gain access to right femoral vein but instead placed the needle into the femoral artery. We were using ultrasound, but the artery and vein were very close together. Patient had some edema from the prior catheter.
We held pressure and aborted the procedure after one arterial stick.
We then shaved and prepped the left groin and attempted to place the catheter in the left groin.
Again, we incurred an arterial puncture. Patient developed a small hematoma. We aborted the left femoral approach. We then attempted the right IJ vein. We were able to gain access but could not thread the guidewire due to a thrombus in the vein. We aborted this procedure, then re-evaluated. The swelling in the left groin had diminished. We again did the ultrasound of the groin, and we were able to see the vein with the ultrasound. We prepped and draped and were able to percutaneously enter the left femoral vein without puncturing the artery. We placed the guidewire dilator over the guidewire and then placed the catheter over the guidewire. We sutured it in place and flushed it.
It flushed easily.

36556

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Left heart catheterization, coronary angiogram, left ventriculogram

93458

Diagnostic mammogram, right

77065-RT

Preoperative Diagnosis: Melanoma, left arm Postoperative Diagnosis: Melanoma, left arm Procedure(s) Performed: Excision Arm Melanoma Re- Re-excision of arm skin lesion/melanoma 7 days postop. Dissection through the previous skin excision of 2.0 cm, down to fascia, and all underlying tissue was removed, including an additional 1.0 cm margin.

11604-58, C43.62

Chronic dacryocystitis with infection Chronic tearing and mattering on her right side. She normally has a very large cystic area that is very painful and expresses greenish-yellow purulent material. Same Incision and drainage of a chronic dacryocystitis the right eyelid The patient was taken to the operating room and prepped and draped. Large amounts of green purulent material were expressed from the right tear sac, and this was sent for culture and sensitivity. A 0 and a 1 Bowman probe were passed through the lower and the upper puncta. I used a 15-blade scalpel to cut down over the tear sac. I used a Westcott scissors to dissect as much of the tear sac to the bone as I could. Then the tear sac wall was incised. Irrigation was done, and nothing passed beyond that tear sac obstruction. I did attempt to probe into the nose before cutting the tear sac, and this was unsuccessful as far as any passage of irrigation. Cautery was used. Gentamicin-soaked packing was placed after the area was copiously irrigated with gentamicin. Both upper and lower puncta were cauterized completely shut in order to eliminate any inflow into the area. It is thought that with no inflow and outflow, this cyst will not reform. Antibiotic ointment was placed.

68420-RT

Preoperative Diagnosis: Wound, tip of nose Postoperative Diagnosis: Wound, tip of nose Procedure(s) Performed: tip of nose STSG Nonhealing wound on the tip of the nose. Documented an autologous split-thickness skin graft (STSG) to the tip of nose. A simple debridement of granulated tissues is completed prior to the placement. Using a dermatome, an STSG was harvested from the left thigh. The graft is placed onto the nose defect and secured with sutures. The donor site is examined, which confirms good hemostasis.

15120

Preoperative Diagnosis: Eye Cataract, Right Postoperative Diagnosis: Same Procedure(s) Performed Cataract Extraction with IOL Implant Phacoemulsification of lens right eye and intraocular lens implant. A 35-degree blade was used to make a stab incision. Anterior chamber was filled with Vitrax. A keratome was advanced through the temporal limbus, and a stab capsulotomy was made with cystotome. Forceps were used to complete the circular capsulorrhexis. Nucleus of the lens was hydrodissected, and phacoemulsification of the nucleus of the lens was carried out. A posterior chamber lens was then introduced into the capsular bag.

66984-RT

Preoperative Diagnosis: Rotator cuff tear, right Postoperative Diagnosis: same Procedure(s) Performed: Diagnostic shoulder arthroscopy, subacromial decompression Diagnostic arthroscopy was carried out and revealed extensive partial thickness tearing of the rotator cuff. This was debrided. There was also a partial thickness tear of the subscapularis that was also debrided and repaired.

29827-RT, M75.121

Incision was started at the flexor surface of the left wrist, the transverse carpal ligament incised, a groove direct or inserted, and the carpal ligament released. After this was completed, the median nerve was identified, and the constricted portion of the median nerve was injected with normal saline solution to accomplish extraneural neurolysis.

64721-LT

Anesthesia for tympanostomy on normally healthy patient

00126-P1

Severe retracted rotator cuff tear (acute), chronic impingement, acromioclavicular arthritis, right shoulder Same Anterior acromioplasty and coracoacromial ligament release, acromioclavicular joint debridement with excision of distal tip of clavicle, repair of chronic avulsion and rotator cuff tendon with transosseous sutures The incision was marked along the anterolateral aspect of the shoulder in a longitudinal fashion, and the dissection was carried down through the subcutaneous fat and fascia. The dissection was carried down subperiosteal and anterior to the AC joint and anterolateral acromion. The elongated and beak type I|I acromion was identified. The anterior acromioplasty was carried out to transform this to a type | acromion. Following this, marked adhesions were noted anteriorly, laterally, and posteriorly. Severe impingement was noted under the undersurface of the AC joint. The AC joint was exposed, and the osteotome was utilized to remove 0.7 cm of the distal clavicle. This allowed marked improvement in the space in the area beneath the distal clavicle. The rotator cuff was severely retracted and was noted to be torn from the area adjacent to the subscapularis, well posteriorly into the teres minor. The tear was carefully advanced, and mattress sutures of 0 Ethibond were utilized X6 for the repair. A trough was made in the area of avulsion, and soft tissue was removed down to bleeding cancellous bone. A margin of cuff was present on the greater tuberosity area, and this was subsequently utilized for interrupted inverted suture repair with 0 Ethibond, following the passage of the transosseous sutures tied along the lateral aspect of the cortex with the arm abducted. Some horizontal portions of the anterior cuff were debrided. There were obvious degenerative changes within the cuff tissue. Partial bursectomy was performed.

23410-RT, 23120-51-RT

Anesthesia services for repair of cleft palate on a normally healthy 6-month-old female

00172-P1, 99100

Preoperative Diagnosis: recurrent bronchogenic ca R/O Postoperative Diagnosis: upper lobe Density, right Procedure(s) Performed: Bronchoscopy The bronchoscope was passed via the left naris without difficulty. The epiglottis and aryepiglottic folds were normal in appearance and color. The vocal cords moved equally and approximated with phonation. Bronchoscope was passed into the tracheobronchial tree. Right upper lobe, right middle lobe, and right lower lobe were all patent with no endobronchial lesions seen. Significant mucus was cleared. Left lower lobe and lett upper lobe were also patent with no endobronchial lesions seen. The bronchoscope was taken through the right upper lobe. Then, with fluoroscopic guidance, brushings and transbronchial biopsies were obtained of the density in the right upper lobe.

31628, 31623-51

Office visit for known diagnosis of hypertension who now presents with symptoms of fatigue and 2-week history of headache. Past history of diabetes and CAD. Cardiovascular, respiratory, and neurologic exams are negative. Patient given beta-blocker for HTN and hypertension-associated headaches. MDM was stated as low.

99213

Preoperative Diagnosis: Leaking breast implant, right Postoperative Diagnosis: Leaking breast implant, right Procedure(s) Performed: Removal leaking breast implant Removal of leaking breast implant. Patient has noted implant increasingly smaller and soft. A pinpoint hole on the posterior aspect of the implant was located. The leaking implant was removed, and the patient elected to not have the implant replaced.

19330-RT

Preoperative Diagnosis: masses right breast TWo Postoperative Diagnosis: Same Procedure(s) Performed: Needle localization right breast lesion(s). Excisional biopsy lesion(s). Frozen section revealing benign fibroadenoma. She was evaluated and found to have a right breast lump. Procedure was to be done with needle localization so the exact lump(s) palpated was (were) the two removed. Earlier today, she was then taken to the x-ray suite where lumps were localized with needles. She was then brought this afternoon for the planned surgery. A small incision was then made next to the entry point of needle. The needle was localized, the area in question was identified; a generous excisional margin was achieved and encompassed the needle and lesion in question. An additional incision was made where the additional lesion was located, and excision of this breast lesion was also performed. All of this was submitted for radiologic evaluation. Frozen section was then done, which showed benign fibroadenoma. At this junction the operation was terminated, and hemostasis was achieved.

19125-RT

Preoperative Diagnosis: Umbilical hernia Post operative Diagnosis: Umbilical hernia Procedure(s) Performed: Repair of umbilical hernia, 12-year-old An elliptical incision was made around the umbilicus. The incision was carried through subcutaneous tissue, all the way to the fascial layer. The hernia sac was opened and excised along the umbilicus. Limited exploration was done. The peritoneum was closed with #0 Vicryl sutures. The fascia that was incarcerated was excised and then closed in imbricating fashion, pushing the lower edge under the upper edge of the fascia. Mattress sutures were taken from above, a distance from the edge, and the edge was incorporated. INDICATIONS AND/OR FINDINGS: The hernia defect measured 2 cm.

49614

Preoperative Diagnosis: Chronic ethmoid sinusitis, Maxillary sinusitis Postoperative Diagnosis: Same Procedure(s) Performed: Endoscopic right anterior ethmoidectomy, bilateral maxillary antrostomy, bilateral frontal sinus exploration

31276-50, 31256-50-51, 31254-51-RT, J32.2, J32.0

A 43-year-old established patient with complaints of rash appeared approximately 2-3 days ago after trip to the country. No other problems such as fatigue, joint pain. Exam reveals diffuse rash over the legs, arms, and back. RX for steroid application to affected areas. Assessment: rash of unknown etiology. MDM was stated as moderate.

99214

Preoperative Diagnosis: Thoracic/lumbar pain Postoperative Diagnosis: same Procedure(s) Performed: Spinal cord stimulator trial; intraoperative spinal cord stimulator screening The lumbar area was prepped and draped in the usual sterile fashion using DuraPrep, and under direct fluoroscopy, the T10 to L2 spinous processes were identified and marked. A small stab wound was made in the L1-2 interspace just above the spinous process. A 15-gauge Tuohy needle was inserted under direct fluoroscopy control through the stab wound and guided into the L1-2 interspace. Under direct fluoroscopy control, the needle was then advanced further until the epidural space was identified using the loss-of-resistance technique. After negative aspiration for blood or CSF was confirmed, a guidewire was inserted through the Tuohy needle and advanced up into the epidural space without any problems. The system was then inserted through the Tuohy needle, and under direct fluoroscopy control, was gradually advanced up into the epidural space in the midline. The final positioning of the tip of the lead was noted to be at the mid body of the T10 vertebra. The stylet inside the quad lead was removed, and a shorter lead connector was inserted into the lead system.

63650

A patient with atrial fibrillation presents for scheduled conversion of atrial fibrillation. After informed consent, the patient underwent IV anesthesia under the guidance of the anesthesia department. The patient received a single, biphasic, synchronized 150-joule external cardioversion, which converted the patient to sinus bradycardia.

92960, 148.91

Preoperative Diagnosis: BCC, chin Postoperative Diagnosis: BCC, chin Procedure(s) Performed: Excision, BCC, chin Diagnosis: Basal cell carcinoma (BCC), left chin. Procedure: Wide local excision of 3.0 cm with 0.3 cm margin BCC of the left chin with a 4 cm closure. A 15-blade scalpel was then used to make an incision in the previously marked site. The lesion was then sharply dissected off underlying tissue bed using a 15-blade scalpel. It was tagged for pathologic orientation. The wound was then closed in layers with 3-0 Vicryl for the deep subcutaneous layer, followed by 5-0 Prolene for the skin.

11644, 12052-51, C44.319

Preoperative Diagnosis: left breast Mass Postoperative Diagnosis: Infiltrating ductal carcinoma Procedure(s) Performed: Excisional biopsy left breast, lumpectomy, and axillary node dissection The left breast and axilla were prepped and draped in the usual manner. The patient had a palpable lump in the upper left breast. A transverse incision was made, and the palpable mass was excised down to the deeper layer. The lesion was about 2 cm above the areola. The specimen was removed and x-rayed and sent to pathology for frozen section. The results were infiltrating ductal carcinoma less than 1.5 cm in diameter with adequate margin, the closest margin being 4 mm from the tumor. While we were waiting for the frozen section, the incision was closed. The decision was made to proceed with lumpectomy and axillary node dissection as agreed to by the patient earlier. An elliptical incision was made, and the incision was carried down to the pectoralis fascia. The previous biopsy site was not entered. The identified mass was completely removed. We then proceeded with the axillary node dissection, which was made through a separate axillary incision about 6 cm in length. This was deepened through subcutaneous tissue. The axilla was entered. Palpable nodes were noted. A few were enlarged and suspicious, about 1 cm in diameter. There was no evidence of any lymph nodes adherent to the nerves or the axillary vein, and the apex of the axilla was clear. The dissection was completed and submitted for pathology.

19302-LT

Preoperative Diagnosis: Internal derangement of the right knee with complex tear of the posterior horn of medial meniscus and associated extensive medial femoral condylar osteochondral defect with chondromalacia and early degenerative osteoarthrosis Module 17 Quiz ... Post operative Diagnosis: Same Procedure(s) Right knee Performed: arthroscopy, arthroscopic partial medial meniscectomy, and arthroscopic abrasion arthroplasty of medial femoral condylar osteochondral defect A short anteromedial portal incision was created with a #11 blade, measuring approximately 1cm in length. The arthroscope and sharp obturator were then advanced through the skin and the capsule and into the joint. The obturator was removed. Upon removal of the obturator, moderate-sized interarticular effusion was evacuated through the arthroscope and fluids submitted to the laboratory for synovial fluid studies. The arthroscope and camera were then advanced into the joint. Arthroscopic examination of the knee was carried out sequentially. Arthroscopic examination was accompanied by several Polaroid films documenting findings throughout the procedure. Arthroscopic examination confirmed a complex multiplanar tear involving the posterior horn of the medial meniscus. This tear was too extensive and fragmented for repair. In addition to the expected tear of the medial meniscus, a substantial defect of the weightbearing surface of the medial femoral condyle was demonstrated; again, this was accompanied by cracking and fragmentation of the margins of the articular cartilage in the area of the lesion. A second stab wound was created for admission of the arthroscopic surgical equipment, and utilizing a 5-0 shaver, as well as a 4-0 shaver, arthroscopic debridement of the torn portion of the medial meniscus was carried out. This was supplemented with hand instruments to attain a clean margin at the level of resection of the posterior horn tear. Following debridement and rejection of the complex medial meniscus tear of the posterior margin, arthroscopic abrasion arthroplasty of the osteochondral defect over the medial femoral condyle was carried out until a smooth margin was created. The base of the lesion was then drilled multiple times, utilizing a small smooth Steinmann pin to reach the osteochondral area for hopeful production of fibrocartilage patching of the defect. Copious and repetitive irrigation of the joint was carried out to evacuate arthroscopic debris of meniscal fragments, as well as the osteochondral lesion.

29881-RT, 29879-51-RT

Post operative Diagnosis: 1. Right renal colic 2. Mild dilatation of the right collecting system, possible right distal ureteral calculus 1. Microscopic hematuria 2. Possible spontaneously passed right ureteral calculus Procedure(s) Performed: 1. Cystourethroscopy 2. Right ureteroscopy 3. Right stent insertion. Anesthesia: General External genitalia were prepped and draped in the usual manner. A #21 panendoscope was inserted transurethrally. Initial inspection of the bladder was not remarkable. Orifices were normal. Right retrograde pyelogram was performed, and the study revealed multiple filling defects, which were felt to represent air bubbles but no stones; however, because the patient's symptoms persisted (her microscopic hematuria and the dilatation of the collecting system on the right side, which persisted all the way down to the right UVJ), we elected to proceed with right ureteroscopy as follows: Glidewire was inserted into the right orifice and advanced all the way to the right renal pelvis, following which the distal right ureter was dilated using a Microvasive balloon dilator, size 12 cm in length, 14 French in diameter. After the balloon was removed, a #10 rigid ureteroscope was introduced transurethrally and advanced in the dilated orifice, and ureter was dilated all the way to the right renal pelvis. No stones, tumors, or other abnormalities encountered. Instrument removed. A #24 ureteral stent was inserted over the glidewire and left indwelling between the right renal pelvis and the bladder.

52351-RT, 52332-51-RT

Preoperative Diagnosis: Abdominal Pain Postoperative Diagnosis: polyp stomach Abdominal Pain, Procedure(s) Performed: EGD EGD with biopsy of gastric polyp. Gastroscope was advanced into the duodenum. Biopsies of the antrum are taken, and a small polyp in the stomach was also biopsied with biopsy forceps.

43239, K31.7, R10.9

Office visit for dressing change to leg performed by physician's nurse. Patient seen previously for wound, result of fall from bike

99211

Patient presents with diagnosis of breast cancer. Expanded problem-focused history and exam and low MDM are performed. Patient has had recurrent problems over the past 5-6 years, and a lengthy discussion regarding treatment options was held with the patient. Thirty-five minutes were spent with patient and 20 minutes spent discussing surgical options, chemotherapy, and radiation treatment options.

99213

Preoperative Diagnosis: Lateral patellar facet syndrome, right knee Post operative Diagnosis: Same Procedure(s) Performed: Arthroscopy, right knee with open lateral retinacular release The right knee was shaved in the proposed incisional location. Tourniquet was inflated to 350 mm of mercury. Arthroscope cannula was introduced via an anteromedial portal at the joint line, followed by the arthroscope. A flow of irrigation was maintained for purposes of visualization and removal of debris. There was no pathology or loose body in the medial gutter. The cartilaginous surfaces of the medial femoral condyle and medial tibial plateau were intact without evidence of fibrillation or breakdown. The medial meniscus showed no evidence of intrasubstance tear or peripheral detachment. The visualized portions of the anterior and posterior cruciate ligaments were intact without evidence of stretching or tearing of their fibers or hemorrhage on their surfaces. The lateral meniscus showed no evidence of intrasubstance tear or peripheral detachment except for the usual detachment in the region of the popliteus tendon, which was not elongated. The lateral gutter showed no evidence of pathology or loose body. A longitudinal skin incision was made laterally adjacent to the patella. The incision was carried through subcutaneous tissue. Full-thickness skin flaps were raised. A nick was made in the lateral patellar retinaculum, and a lateral patella release was performed in its entirety. This freed up the lateral aspect of the patella as visualized arthroscopically, which allowed better lift-off and enhanced medial glide of the patella. The lateral release incision was closed with interrupted vertical mattress sutures of 3-0 Ethilon.

27425-RT

Surgical scrub to lower neck under fluoroscopic guidance. C7-C8 intervertebral space was identified. The skin was infiltrated with 1% lidocaine, 2 cc. Epidural needle #17 Tuohy, loss-of-resistance technique; loss of resistance positive. Needle position confirmed by fluoroscopy, and 2 cc of 0.25% bupivacaine injected as a test dose. Test dose was negative. No CSF, no heme on aspiration. Then 5 cc of normal saline preservative-free with 40 mg of Depo-Medrol was injected through the epidural space, and the needle was removed. Two trigger points were done on the right side, one at the right paravertebral neck and the second at the right suprascapular region. Each trigger point was injected with 2.5 cc of 0.25% bupivacaine and 20 mg of Depo-Medrol to each side.

62321, 20552

X-ray: X-ray of left thumb was reviewed and was negative for fracture. Possible minimal degenerative joint disease. Physician's Report: HPI: Patient reports jamming thumb into wall last night and woke up this AM with bruising, pain, and decreased range of motion at the interphalangeal joint. Minimal pain per patient. He denies numbness, tingling, or weakness. ROS: Positive extremity pain, no fevers, all other symptoms reviewed are negative. PMH/SH: Unremarkable EXAM: Vital signs are stable, well-nourished, and in no acute distress. Respiratory: Clear to auscultation Extremity: Left thumb, bruising of thumb pad with decreased extension of IP joint secondary to pain. Possibly minimal tenderness to palpation at IP joint. Neurovascular intact. Other fingers and extremities without injury. Metal splint was applied to left thumb. IMPRESSION: Left thumb contusion

29130-FA

Right knee arthroscopy and chondroplasty of patella; right knee arthroscopy lateral release After suitable general anesthesia had been achieved, the patient's right knee was prepped and draped in the usual manner. The arthroscope was inserted through an anterior lateral portal. The medial compartment was examined first. There was noted to be intact stable medial meniscus and intact articular surfaces. Examination of the notch revealed intact and stable ACL and PCL. Examination of the lateral compartment revealed intact articular surfaces and intact and stable lateral meniscus. Examination of the patellofemoral joint revealed localized chondromalacia at the lateral aspect of the inferior pole of the patella. This was smoothed with a shaver and further smoothing was done using an Oratec probe. The patient was noted to have a small medial synovial plica and this was trimmed with the shaver as well. Using an arthroscopic cautery, arthroscopic lateral release was done from the superior pole of the patella to the joint line. Following this, the knee joint was thoroughly irrigated and the arthroscope removed.

29873-RT

Preoperative Diagnosis: Breast mass Postoperative Diagnosis: Breast mass Procedure(s) Performed: Excisional biopsy A 78-year-old female had recent mammographic and ultrasound abnormalities in the 6 o'clock position of the left breast. She underwent core biopsies, which showed the presence of a papilloma. The plan now is for needle localization with excisional biopsy to rule out occult malignancy. After undergoing preoperative needle localization with hookwire needle injection with methylene blue, the patient was brought to the operating room and was placed on the operating room table in the supine position, where she underwent laryngeal mask airway (LMA) anesthesia. The left breast was prepped and draped in a sterile fashion. A radial incision was then made in the 6 o'clock position of the left breast corresponding to the tip of the needle localizing wire. Using blunt and sharp dissection, a generous excisional biopsy was performed around the needle localizing wire, including all of the methylene blue-stained tissues. The specimen was then submitted for radiologic confirmation followed by permanent section pathology.

19101-LT, D24.2

Preoperative Diagnosis: Chronic Sinusitis Postoperative Diagnosis: Chronic Sinusitis Procedure(s) Performed: Utilizing a 5" sinuscope and microdebrider, the anterior wall of both ethmoids was removed with the microdebrider, and the hypertrophic mucosa and anterior ethmoid cells were cleared with the microdebrider. The maxillary sinus ostia were cleared of hypertrophic mucosa on the right side, followed by the same procedures on the left.

31267-50, 31254-50-51

Right knee arthroscopy, arthroscopic partial medial and lateral meniscectomy A short anteromedial portal incision was created with a #11 blade, measuring approximately 1 cm in length. The arthroscope and sharp obturator were then advanced through the skin and the capsule and into the joint. Arthroscopic examination of the knee was carried out sequentially. Arthroscopic examination was accompanied by several Polaroid films documenting findings throughout the procedure. Arthroscopic examination confirmed the preoperative MRI findings of a complex multiplanar tear involving the posterior horn of the medial meniscus as well as a tear of the lateral meniscus. These tears were too extensive and fragmented for repair. A second stab wound was created for admission of the arthroscopic surgical equipment, and utilizing a 5-0 shaver, as well as a 4-0 shaver, arthroscopic debridement of the torn portion of the medial and lateral meniscus was carried out.

29880-RT

Closed reduction, intermedullary nailing radius and ulna INDICATIONS FOR PROCEDURE: This is a 10-year-old female who sustained a both-bone forearm fracture and was treated with closed reduction and casting initially. She had gone on to malposition, despite appropriate casting, and the patient states that she had been wrestling with her brother, hitting her brother on top of the head with her cast. After discussion of the options, risks, and benefits of the surgical procedure, all questions were answered and consents were signed. The patient was taken to the operating room. The patient was taken to the operating room and placed supine on the operating room table. General anesthesia was obtained. The cast was then removed from the upper extremity. Obvious deformity was identified. Reduction of the radius and ulna were then able to be obtained with C-arm to verify adequacy of reduction. We then made a 1-cm incision over the area of Lister's tubercle, just proximal to the distal growth plate. We placed a 2.0-mm titanium flexible rod into the intermedullary canal of the radius/ulna and passed this past the fracture site. It was then bent and cut off. This was then sewed up with 3-0 Monocryl after irrigation with Bacitracin saline solution. The patient was placed into a well-padded long-arm cast.

25415-RT

Preoperative Diagnosis: Ethmoid Sinusitis, Maxillary Sinusitis Postoperative Diagnosis: same Procedure(s) Performed: Endoscopic ethmoidectomy, bilateral, right maxillary antrostomy, concha bullosa resection, left

31254-50, 31256-51-RT, 31240-51-LT

1. Exam under anesthesia 2. Laparoscopy 3. Lysis of adhesions. Anesthesia: The patient was placed in the lithotomy position and prepped and draped in the usual fashion. Foley catheter was placed in the bladder. Hulka tenaculum was then placed in the uterus for manipulation. A small 5-mm infraumbilical incision was made, through which a Veress needle was passed without difficulty. After adequate insufflation with carbon dioxide gas, a 5-mm trocar was passed without difficulty. The laparoscope was passed through this, and an intra-abdominal adhesion was noted. A suprapubic incision was made, 5mm, in the midline, through which a 5-mm trocar was passed under direct visualization. The pelvis was inspected, and the findings were as follows. There were also deep black endometriotic implants along both uterosacral ligaments. Deeper in the cul-de-sac were red endometriotic implants. The right ovary was adhered to the right side of the uterine wall, and this was taken down bluntly. The cyst in the ovary was opened up, and brown fluid could be seen coming from the cyst, which would be consistent with an endometrioma. It was opened completely and irrigated. The right adnexa was completely dissected off the uterus by blunt dissection. The lower sigmoid, upper rectal area was also dissected off the posterior wall of the uterus by blunt dissection. The sigmoid colon on the left, however, was adhered to a point just below the left ovary. This made it difficult to see the left ovary completely. However, the laparoscope was passed through the suprapubic cannula, and this allowed us to see the distal part of the tube. Both fimbriae appeared to be normal. There were some brown implants of endometriosis on the left ovary. The pelvis was extensively irrigated. The suprapubic cannula was removed under direct visualization without subsequent bleeding. CO2 gas was released through the umbilical cannula, which was then removed. Both incisions were closed with Dermabond. Hulks tenaculum was removed from the cervix without subsequent bleeding.

49322

Upper Performed: gastrointestinal endoscopy and foreign object removal Patient is a 4-year-old who swallowed a quarter. X-ray confirms position in the high esophagus. The patient was brought to the endoscopy suite, where continuous oximetry, blood pressure, and EKG monitoring were placed. Oral airway was placed. The Olympus flexible fiberoptic endoscope was introduced through the pharynx without difficulty. Immediately upon entering the esophagus, the coin was noted. This was grasped with a tooth tenaculum and then pulled intact from the esophagus. IMPRESSION: Foreign object, 25-cent piece in esophagus, removed

43215, T18.198A

Release Dupuytren contracture, both hands Under adequate regional anesthetic, patient was prepped and draped in a sterile manner, and the left hand was released first. Incision was made over the palm. The 4th and 5th fingers were the ones that were tight, and these were carefully released, dissecting down, removing the thickened fascia scar layer of Dupuytren. This was completed while carefully preserving all neurovascular structures; both of the fingers were released so they would extend nicely without any tension and were quite free. Once release was completed and meticulous hemostasis was obtained, the incision was closed with Proline sutures. Attention was then turned to the opposite, that is, the right hand. On this hand the thumb was quite tight, and this had to be released. Incision was made over the palmar contracture, and it was carefully dissected off and removed completely. This freed the thumb completely, and it moved well and easily. Following this, then the 5th finger was released as well. However, there was ankylosis of the joint, that is, the proximal interphalangeal joint, and this could not be freed. The contracture portion was freed so that the MP joint would move well, but with the ankylosed joint, this could not be released. Upon release of these, while carefully protecting all neurovascular structures and with meticulous hemostasis being obtained, these incisions as well were closed with Proline sutures.

26123-50, 26125-RT, 26125-LT, M72.0

Transposition of the ulnar nerve, right elbow, and release of carpal tunnel, right wrist and hand The medial right elbow was approached through a curving posteromedial incision. The ulnar nerve was identified proximally. A Penrose drain was placed around it, and it was followed to the cubital tunnel and freed from the tunnel and dissected distally to the flexor carpi ulnaris. Hemostasis was obtained, and the nerve was freed along its course until it could easily be positioned medially anterior to the epicondyle. The subcutaneous pocket was fashioned in this location, and 2-0 Vicryl was used to close the pocket over the ulnar nerve in its new position. There was no undue tension. Attention was turned to the right hand, which was placed on the hand table, and a palmar incision was made in line with the 4th ray, extending from the distal flexion crease of the wrist distally to the proximal flexion crease of the palm. The palmar aponeurosis was divided. The superficial arterial arch was protected ulnarly, and the flexor tendons were identified and followed to the carpal ligament, which was cleared on both its superficial arterial arch was protected ulnarly, and the flexor tendons were identified and followed to the carpal ligament, which was cleared on both its superficial and deep surfaces so that it could be divided under direct vision. The ligament was divided well in the distal forearm to ensure complete incision of the transverse carpal ligament. Copious irrigation of the wound was carried out. The median nerve lay radially in the carpal tunnel. External neurolysis was performed. Staples were then used to close the elbow incision, and a sterile, bulky Robert Jones dressing was applied with the Bunnell hand dressing. The wrist was held in dorsiflexion with a splint, and a posterior splint was applied to hold the elbow in 90 degrees of flexion.

64721-RT, 64718-51-RT

Procedure(s) Performed: Anterior capsulorrhaphy, left shoulder Anesthesia: The patient was placed supine on the operating room table on the beach chair attachment, and a satisfactory general anesthetic was given. The incision was carried through subcutaneous tissue. Full-thickness skin flaps were raised. The subscapularis muscle was then split perpendicularly to its fibers to encounter the joint capsule. The joint capsule was freed up. The articular surfaces of the glenoid and humeral head were intact without evidence of fibrillation breakdown or cartilaginous cracking. The anterior labrum was noted to be well situated on the anterior glenoid. An anterior capsulorrhaphy was then performed in a north-south type fashion with O Ethibond sutures. The subscapularis was reapproximated to its normal length with interrupted figure-of-eight suture of 0 Ethibond.

23450-LT

CT abdomen, with and without contrast

74170

Right lateral tennis elbow release with elbow arthrotomy and exploration INDICATIONS FOR PROCEDURE: The right arm was prepped and draped in the usual sterile fashion. A standard lateral incision was made directly over the lateral epicondyle. Subcutaneous tissue was dissected down to the deep fascia. The deep fascia was identified, and the interval between the ECU and extensor carpi radialis longus was identified and split. As this was separated, we identified the extensor carpi radialis brevis. It was subsequently released from its origin onto the lateral humeral epicondyle, and there was significant scar tissue beneath this. This was subsequently debrided off, and we inspected the radial capitello joint, found no evidence of any loose bodies with good smooth articular cartilage. We then closed the capsule up with 3-0 Ticron.

24358-RT

Colonoscopy Colonoscopy with biopsy of polyp, excision of another polyp by snare technique, and fulguration of bleeding at bases of excisions

45385, 45380-59, K63.5, K92.1

Circumcision The patient was brought to the nursery and placed on the circumcision board. His legs were strapped down. The base of the penis was cleansed with alcohol, and 1% lidocaine without epinephrine was injected at the 10 and 2 o'clock positions. Less than 1 cc of 1% lidocaine was used. Hemostats were placed at the 9 and 3 o'clock positions to help with holding while adhesions were taken down from the glans. Adhesions were taken down, taking great care not to injure the glans. Hemostat was then placed at the dorsum sagittal line down to just distal to the corona. Hemostat was left in place for approximately 1 minute. After removal of the hemostat, an incision was made down to the apex. The foreskin was then retracted and further adhesions were removed. The foreskin was surgically excised. There was oozing of blood along the volar aspect or frenulum part of the penis. Pressure was applied to this area. This was not enough to maintain hemostasis, so silver nitrate sticks were used with good results. The penis was then dressed with Vaseline gauze, and patient was placed on observation status to watch for any signs of continued bleeding.

54160

Treatment of incomplete abortion.

59812

Hysteroscopic dilation and curettage were performed with endometrial biopsy.

58558

Microdirect laryngoscopy with CO2 laser excision of polyps/papilloma All precautions, set-up, and preparation of the patient for use with the CO2 laser were taken prior to initiation of the procedure. The anterior commissure laryngoscope was entered into the oral cavity and passed down to the level of the vocal cords. It was placed into position using the Lewy suspension. The polyp on the left vocal cord was immediately visible. There was a small polyp on the left false vocal cord as well. The right true vocal cord had a small polyp in the very anterior-most region near the anterior commissure. A biopsy of these was taken and sent to Pathology. Grossly, these definitely appeared to be papillomas. CO2 laser was used to carefully excise the papillomas without injuring the vocal cords themselves. Hemostasis was achieved with Afrin-soaked cottonoids.

31540

Colonoscopy with hot biopsy and polypectomy with snare Description of Procedure: Digital rectal examination was done first, and then colonoscope Olympus GIF 140 was introduced and advanced all the way up to the cecum, identified by ileocecal valve and appendicular orifice. Of note of importance, she does have a lot of twist, almost a 360° twist, in the area of transverse and descending colon and also in the proximal ascending colon as well. Beyond the cecal valve was an area which appeared to be flat with cauliflower-looking appearance on top of which was an almost flat lesion, no pedicle, spread over approximately 0.8 mm in size in cross-section. No ulceration observed. It was a little bit friable, and I took a few biopsies, hot and cold, from that area. A minimum amount of blood oozing. The rest of the colon appeared normal. She had a few pockets of stools that were washed away. In the area of the sigmoid region, two polyps were identified, which were seen on air contrast barium enema. Both were in close approximation and were snared in toto and retrieved with suction. The rest of the colon was entirely normal. She does have moderate-sized internal hemorrhoids.

45385, 45380-59

Preoperative Diagnosis: Pleural effusion, hx of breast ca with metastasis Postoperative Diagnosis: Same Procedure(s) Performed: Thoracentesis A thoracentesis kit was used with aspirating catheter. The patient was prepped in the posterior position with Betadine and the catheter was advanced into the intercostal space, the mid clavicular line, two interspaces below the scapula after 1% local lidocaine anesthesia. 1 liter of cloudy amber fluid was removed. The patient had some mild chest tightness, so no further fluid was removed at this time. Marked decrease in shortness of breath. The patient tolerated the procedure well. Study was sent for cytology, chemistry, and micro.

32554

Procedure(s) Performed: Pacemaker Replacement Same Temporary Temporary pacemaker implantation for stabilization was placed approximately 10 days ago, performed in the OR Implantation of permanent ventricular pacemaker now being placed.

33207, 147.20

Endoscopic left total ethmoidectomy. Left middle meatal enterostomy. Left partial middle turbinectomy. The nose was vasoconstricted with topical Afrin and injected with 6 cc of 1% lidocaine with 1:100,000 parts of epinephrine into the left middle turbinate and lateral nasal wall mucosa. Using a two-view monitor for visualization, the 0-degree sinus endoscope was placed in the left nasal cavity, and the left middle turbinate was lateralized with a Freer elevator. Using the sharp edge of the Freer, the anterior ethmoid air cells were entered, and bone and mucosa were removed with straight and upbiting forceps. The left maxillary sinus ostia were identified, and an enterostomy, approximately 1 cm in diameter, was made with the upbiting forceps and power microdebrider. The left maxillary sinus cavity was examined with a 30- and 70-degree sinus endoscope, and it showed chronic, thickened mucosa, which was removed. The left total ethmoidectomy was completed with forceps and the power microdebrider. An anterior inferior portion of the left middle turbinate was excised with turbinate scissors.

31267-LT, 31255-51-LT, 30130-51-LT

Right myringotomy with tympanostomy tube placement, local Utilizing the ear speculum and ear microscope, the external canal was cleared of cerumen. The tympanic membrane was very sclerotic in the posterior aspect. As such, a myringotomy incision was placed in the anterior quadrant. Serous effusion was suctioned. A Bobbin tympanostomy tube was then placed without difficulty. Cortisporin otic suspension and cotton ball were then placed. The patient tolerated the procedure well; there was no break in technique. The patient was taken to the recovery room in good condition.

69433-RT

Procedure(s) Performed: 1. PIPJ resection arthroplasty, 4th digit, right foot 2. Exostosectomy, distal medial 5th toe, right foot INDICATIONS FOR PROCEDURE: The patient is a 49-year-old male who has painful hammer toes with associated keratotic lesions on 4th and 5th digits of right foot. Attention was then directed to the dorsal aspect of the 4th digit where a 1.5 cm dorsal linear incision was made, beginning at the mid shaft of the proximal phalanx and extending distally to the mid shaft of the middle phalanx. The incision was deepened via sharp and blunt dissection with care to identify and retract all neurovascular structures. Hemostasis was obtained as needed. The incision was deepened down to the level of the extensor tendon, which was then transected at the level of the PIPJ. The medial and lateral collateral ligaments were released. The extensor tendon was reflected proximally. Using a sagittal saw, the distal third of the proximal phalanx was resected. Attention was then directed to the dorsal distal and medical aspects of the 5th digit, right foot, where a 1-cm dorsal medial linear incision was made over the distal phalanx. The incision was deepened down to the level of the distal and medial condyles. Using a handheld rasp, this bone prominent area was resected.

28285-T8, 28285-T9

Procedure(s) Performed: Cysto History of bladder Ca, repeat cysto. 16-French flexible cystoscope was inserted and passed into the bladder. The bladder showed no signs of tumor recurrence.

52000, 285.51

Procedure(s) Performed: Reconstruction Metacarpophalangeal Ligament, Right Incision carried down to the right metacarpophalangeal joint. Incision was made directly over the capsule, exposing the metacarpophalangeal joint. The extensor digitorum brevis tendon was exposed, and a tendon graft was taken from the extensor digitorum brevis tendon. A drill hole was made at the previous attachment of the metacarpophalangeal ligament and exiting dorsally on the proximal phalanx. Through this hole, the extensor digitorum brevis tendon was rerouted exiting the ulnar side of the joint. Two similar holes were then drilled on the metacarpal head of the thumb, and the tendon graft was pulled through these two holes, reestablishing ulnar collateral ligaments.

26541-RT

EXAM: General: White 71-year-old male, well-nourished and in acute distress. HEENT: 1-cm laceration to occipital scalp. Eyes, pupils equal, round, and reactive to light, extraocular motion intact. Respiratory: Respirations unlabored with symmetric chest expansion. Lungs sound equal and clear bilaterally. CV: Regular rate and rhythm. Abdomen: Soft, non-tender to palpation Skin: Normal, except for 1-cm laceration PROCEDURE: The area was prepped and draped, and the wound was cleansed thoroughly with betadine. Wound was irrigated with copious amounts of NS. Skin closure was accomplished with 2 staples. Impression: 1-cm scalp laceration

12001

Patient returns after MRI knee performed. MRI was within normal limits, and no meniscus tear was shown. Diagnosis is severe contusion of the inferior pole of the patella. In view of this, she will immobilize her knee and arrange for physical therapy for her. Problem-focused history and low MDM were performed.

99213

Procedure(s) Performed: Dual-chamber pacemaker placement in left subclavian. Guide wire was positioned to the level of the right atrium. Cutdown made and tear-away sheath passed over the wire. The ventricular lead was manipulated into the right ventricular apex. The atrial lead was then manipulated into place in the same fashion. The leads and the pacemaker were placed into the newly created pocket and connected and tested. The pocket was closed and patient was stable.

33208, R00.1

Procedure(s) Performed: injections Trigger point Trigger point injections. Patient with myofascial pain syndrome in the lower lumbar and upper sacral areas. Palpation of the longissimus muscle and the multifidus muscle for a total of eight trigger points. Trigger points were marked, and Marcaine 0.25% was injected into each trigger point.

20552

Procedure(s) Performed: Arthroscopic lateral release, right Right knee arthroscopy, chondroplasty of patella arthroscopic lateral release. Examination showed localized chondromalacia of the lateral aspect of the patella that was smoothed with a shaver. Patient was noted to have small medial synovial plica that was trimmed with the shaver as well. Using an arthroscopic cautery, an arthroscopic lateral release was performed from the superior pole of the patella to the joint line.

29873-RT

Procedure(s) Performed: 1. Placement of a right internal jugular single-chamber mediport. The patient recently presented to my office with a history of colon cancer and is undergoing chemotherapy. He has very poor peripheral IV access, and he presents for the above procedure. After adequate IV sedation was achieved, the patient's right neck and upper chest were prepped and draped in standard surgical fashion. Using 1% lidocaine, I carefully anesthetized an area over the anterior border, sternocleidomastoid muscle, as well as onto the anterior chest wall. Using a Seldinger technique, a guidewire was placed into the right internal jugular vein to the superior vena cava. This was verified using intraoperative fluoroscopy. I then made a pocket under the right anterior chest wall using the 15-blade and electric Bovie cautery and created it so that the Infuse-A-Port would fit comfortably into the pocket. Then, using the dilator introducer system, these were placed over the guidewire into the internal jugular vein. The guidewire and dilator were then removed, and the catheter itself was threaded into the superior vena cava. Again, its position was verified using intraoperative fluoroscopy. I then used the tunneling device and then used the tunneling device and tunneled the catheter onto the anterior chest wall, hooked it up to the Infuse-A-Port, and placed the Infuse-A-Port into the pocket. I ensured that the Infuse-A-Port worked properly using heparinized saline, both aspirating and then flushing. I then closed the pocket using a 3-0 Vicryl suture, and the skin was closed with subcuticular 4-0 Monocryl.

36561

Procedure(s) Performed: same TAH BO Abdominal hysterectomy with oophorectomy

58150, N93.8

1. Right endoscopic antral ethmoidectomy 2. Right endoscopic maxillary antrostomy with removal of polyp from maxillary sinus The patient's nose was packed with cotton pledgets soaked with 4% cocaine. After several minutes, 1% Xylocaine with 1:100,000 units epinephrine was infiltrated into the inferior and middle turbinates, as well as in the lateral nasal wall anterior to the medial meatus. Then utilizing the 5° sinuscope, the middle turbinate was medialized. Then, utilizing a sickle knife, biting forceps, and microdebrider, the uncinate process was removed. Hypertrophic mucosa was noted to be filling the area of the lateral nasal wall and the anterior wall of the ethmoid bulla. This was removed with the microdebrider. This was cleared. Subsequently, the anterior wall of the ethmoid bulla was incised and then the anterior wall was removed with the microdebrider. Hypertrophic mucosa filling the anterior ethmoid air cells was then removed with the microdebrider. The maxillary sinus was then addressed. Thickened mucosa was affecting the ostia. This was incised and thickened polypoid mucosa was removed from the ostia as well as the sinus. The ostia was widened in a posterior-inferior direction. The area was then packed with cotton pledgets soaked with 1:50,000 units of epinephrine.

31267-RT, 31254-51-RT

Procedure(s) Performed: Excision gynecomastia left breast In surgery with an IV line in place, he received IV anesthetics for sedation. Then the left breast, left chest wall was cleaned with DuraPrep and draped. The left breast was markedly enlarged, consistent with gynecomastia, and benign. My incision was going to be a circumareolar incision. The areolar complex was immobilized and elevated. Then the margins of the breast around the areola were now dissected circumferentially until all breast tissue was marked out. It was then dissected out from the pectoralis muscle until all of the tissue was removed. The breast was then removed in toto and submitted for frozen section exam that confirmed that this was a benign gynecomastia.

19300-LT

Colonoscopy with polypectomy and electrocoagulation with arteriovenous malformation Next, digital rectal exam was performed revealing no mass, external hemorrhoids, good tone, and enlarged prostate. Next, the Olympus CP-160L colonoscope was introduced into the patient's rectum and passed throughout the colon into the cecum. Free intubation of ileocecal valve and terminal ileum was not achieved. In the cecum, there were a couple of bleeding AVMs. These were treated with 8 French BICAP probe, 20-watt setting. Successful obliteration of AVMs. There was another one in the ascending colon that was also electrocoagulated. There were a few scattered diverticula noted in the right colon and ascending colon. There was a 5-mm polyp removed by hot snare polypectomy and placed in jar B. In the transverse colon, there were a few scattered diverticula, but no polyps, no AVMs. In the descending and sigmoid colon, there were scattered diverticula, but no polyps, no AVMs. The endoscope was brought back into the rectum. There were a couple of 2-mm polyps removed by fulguration polypectomy. IMPRESSION: 1. Colon polyps 2. AVMS 3. Diverticulosis coli 4. External hemorrhoids

45388, 45385-59, 45382- 59

Septoplasty. Columella reconstruction with cartilage graft The patient's nose was prepped with Betadine prep and then draped in a sterile manner. Patient's nose was packed with cotton pledgets soaked with 4% cocaine. After several minutes, an intranasal injection of 1% Xylocaine to 1:100,000 units epinephrine was made. In addition, infiltration was also done in the columella. Then utilizing a right hemitransfixion incision, bilateral mucoperichondrial and mucoperiosteal flaps were elevated. There was a significant amount of scarring around the cartilaginous septum. There were several fractures in the septum. Portions of the cartilaginous septum were missing. As such, under dissection there were several tears in the mucoperichondrium. Remnants of the cartilaginous septum were removed except for a dorsal strip. Portions of the bony septum were then removed. Spurs off the maxillary crest were also removed. The tears in the mucoperichondrium were reapproximated as best as possible with 4-0 chromic sutures. Attention was then focused on the columella. Utilizing an interior columella incision, the excess tissue at the base of the columella was excised. Excessive scar tissue was excised. Subsequently, a tip support was reconstructed with cartilaginous graft obtained from removed cartilaginous septum remnants. The medial crura were reapproximated with the cartilage graft.

30520, 13151-59

Procedure(s) Performed: Open reduction and K-wire fixation of left small finger proximal phalanx fracture Open reduction of the left small finger proximal phalanx fracture was achieved and K-wires were cut. The tourniquet was deflated and hemostasis was achieved with bipolar cautery. The extensor tendon was repaired with running 4-0 Vicryl sutures. Next, the skin was closed with interrupted 4-0 nylon sutures. Caps were placed on the K-wires. Xeroform and Bacitracin were placed over the K-wires and incision, and 4 × 4 fluffs were placed in between the fingers and around the K-wire pins for padding. The hand was wrapped in cast padding and two 10-plys of 4-inch plaster were applied along the volar and ulnar aspects of the hand to maintain the fingers and hand in reduction. This was then wrapped with 3-inch and 4-inch Ace wraps.

26735-F4

D&C for control of menopausal bleeding Procedure was to be done with local IV-monitored anesthesia. She was sedated IV-wise and then placed in the lithotomy position following perineal/vaginal prep. Operation was started. Weighted speculum was inserted into the posterior vagina. The anterior cervix was secured with tenaculum and weighted. Hegar's dilators were utilized to size 12, and then a sharp curet was passed in, curetting generous amounts of endometrial tissue until nothing else could be felt except the firm, gritty sensation of myometrium.

58120, N95.9

Esophagogastroduodenoscopy Mouth was sprayed with Cetacaine and then mouth block was applied. Esophagogastroduodenoscopy scope was passed in the mouth and easily intubated. Visually guided in the esophagus. The proximal esophagus showed longitudinal ulcer with clean margins at 16 cm. Scope was further advanced. No stricture or masses seen. The distal esophagus appeared normal. Scope was further advanced into the stomach. Rugae appeared normal, which flattened out normally on insufflation. The scope was advanced all the way to pylorus that appeared normal in size and shape. Scope was pushed into the duodenal bulb, which appeared normal, and scope was advanced beyond the 3rd part of the duodenum. A couple of biopsies were taken from the small bowel mucosa. Scope was withdrawn all the way back into the antrum. Retroflexion was done. The scope was straightened out, pulled back all the way up to the GE junction. Excess air was suctioned out. Then reexamined the esophageal ulcer at 16 cm, which extends from 16 to 17 cm, in a longitudinal fashion. One biopsy was taken.

43239

The patient was placed supine on the operating room table and a satisfactory general anesthetic was given. The left hand was draped in the usual sterile fashion. Tourniquet was inflated to 250 mm of mercury. Oblique skin incision was made over the proximal phalanx of the left long finger on the volar surface. The incision was carried through subcutaneous tissue. Hemostasis was achieved as necessary. Full-thickness skin flaps were raised. Flexion creases were not crossed. Gentle blunt dissection was performed deeply. The entrance site of the three BBs was found and the three BBs were gently delivered into the wound and removed. The wound was copiously irrigated with normal saline antibiotic solution.

10120

Office visit for known asthmatic for regular follow-up. No complaints other than shortness of breath with exercises, resolving with nebulizer treatment x2. No fatigue, no chest pain. Exam includes respiratory, cardiovascular, ENT, and constitutional. Asthma controlled. MDM was documented as low for this encounter.

99213

Procedure(s) Performed: Diagnostic scope with attempted biopsy. Anesthesia: A dilator was used as a manipulator, and the uterus was sounded to 9 cm. Surgeon changed gloves, and laparoscopic portion was commenced. Initially, a Veress needle was used, but I could not maintain appropriate pressure, so the 12-mm trocar was then inserted and the scope passed to ensure proper location and lack of injury. CO2 was then insufflated to a pressure of 12 mm, and an additional 5-mm suprapubic puncture was made. Examination of the upper abdomen and pelvis was performed, and an attempt was made to biopsy the tubal cyst area. The peritoneal discolorations were documented on film. Following this, hemostasis was noted, and the CO2 gas was allowed to escape after initial frozen-section reports came back as negative. The instruments were removed, and the incision sewn with 4-0 undyed Vicryl in a subcuticular fashion with a deep stitch being placed in the 12-mm site.

49321-52

In the outpatient setting, a detailed history and exam are performed on an established patient. The patient presented for an acute uncomplicated problem, no imaging was performed and a prescription was given. Assign the appropriate E/M for this service.

99213

Epidural anesthetic injection, T1-T2 with imaging guidance

62321

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