Respiratory/CardiovascularPre-op diagnosis: Left lung absces…

Respiratory/CardiovascularPre-op diagnosis: Left lung abscessPost-op diagnosis: SameProcedure performed: Left upper lobectomy with decortication and drainageIndications: The patient is a 56-year-old female with evidence of a left upper-lobe abscess seen on the MRI. She was admitted with tension pneumothorax, which was treated with double-lumen intubation and a chest tube.Procedure: The patient was brought to the operating room and placed in the supine position, with general intubation from the double-lumen tube. The patient was rolled onto the right lateral decubitus position, with left side up. A posterior lateral thoracotomy was performed. Adhesions were taken down sharply and bluntly and with cautery. Following this a standard artery first left upper lobectomy was carried out utilizing 0 silk and hemoclips. The left upper pulmonary vein was secured with a single application of the stapling machine. The posterior fissure was created with multiple applications of the automatic stapling machine and the bronchus secured with a single application of the bronchus stapling machine. Following this the wound was drained with three 24-French strium chest tubes and hemostasis obtained with spray Tisseel and surgical gauze. The bronchus was sealed with bio glue and the wound closed in layers. A sterile compression dressing was applied, and the patient was returned to the surgical intensive care unit after the double-lumen tube was changed to a single-lumen tube. The patient received 3 units of packed cells intraoperatively to maintain hemostasis. Sponge count and needle count correct × 2. Large abscess in the left upper lobe accounted for approximately 70% of the left upper-lobe parenchyma.Select the appropriate ICD-10-CM and CPT code(s):

RadiologyUpon orders from Dr. Clyos, a portable x-ray machin…

RadiologyUpon orders from Dr. Clyos, a portable x-ray machine was transported to the city nursing home for chest x-rays of a patient with possible tuberculosis. The diagnosis was nodular lesions and patchy infiltrates in the upper lobes. Select the appropriate ICD-10-CM and CPT code(s):

MedicineA 55-year-old female was having a problem with menop…

MedicineA 55-year-old female was having a problem with menopause. Because of the reported concerns about hormone replacement therapy, she decided to try acupuncture. After discussing her symptoms and discussing a treatment plan, Dr. Kind inserted several needles; the needles were removed 20 minutes later. Dr. Kind reviewed the follow-up plan and made an appointment for the patient’s next visit. Dr. Kind spent 30 minutes in total face-to-face with Charlene. Select the appropriate ICD-10-CM and CPT code(s):

Nervous System, Eyes, Ears, EndocrinePreoperative diagnosis:…

Nervous System, Eyes, Ears, EndocrinePreoperative diagnosis: Right subdural hematomaPostoperative diagnosis: Right subdural hematomaProcedure performed: Right temporoparietal craniotomy for evacuation of subdural hematomaAnesthesia: General endotrachealComplications: NoneConditions: StableIndications for procedure: Mr. Green is a 45-year-old male with a known history of alcoholism. He reported falling today, with loss of consciousness for about 20 minutes. Upon arrival at the ED, he was minimally responsive, with some spontaneous movement on the right side. He was intubated and taken to CT, which demonstrated a large right temporal subdural hematoma with 2.5-cm midline shift and effacement of the right lateral ventricle.Description of procedure: The patient was brought to the OR already intubated. General anesthesia was induced. He was given Ancef for preoperative prophylactic IV antibiotics. Lacri-Lube was placed in both eyes, which were then taped shut. A Foley was placed. The patient was positioned supine on the operating room table with the right side elevated with a gel roll. The head was secured in the three-point Mayfield head-holder with the right side up. All pressure points were inspected and padded adequately. The patient’s scalp was clipped, prepped, and draped in standard sterile surgical fashion. Local anesthetic was infiltrated along the line of the planned skin incision. A right temporoparietal inverted-question-mark incision was performed with a #10 blade down to the level of the periosteum. The scalp flap, along with the muscle and periosteum, was elevated and reflected anteriorly and held in place with fishhooks. Raney clips were applied to the skin edges. Using the high-speed Midas Rex drill with the perforator bit, burr holes were placed in the temporoparietal region, and they were connected with the B1 and footplate. The bone flap was elevated from the dura and set aside. The underlying brain appeared to be tense. The dura was opened with a 15-blade, and a large amount of subdural hematoma was immediately released. The subdural space was copiously irrigated, and hemostasis was achieved.Select the appropriate ICD-10-CM and CPT code(s):

MusculoskeletalMrs. Jones is in the operating room today for…

MusculoskeletalMrs. Jones is in the operating room today for repair of a nontraumatic tear of the rotator cuff of the right shoulder. The physician performs an arthroscopy subacromial decompression with an open repair of the rotator cuff. Select the appropriate ICD-10-CM and CPT code(s):

PathologyHistory: 76-year-old female with colonic massDiagno…

PathologyHistory: 76-year-old female with colonic massDiagnosis: Invasive adenocarcinoma, 3.4 × 3.0 cm, involving muscularis propriaAll margins negative.No lymphatic invasion.No metastatic tumor identified.Gross description: Received fresh is a right colon, 32 cm in length. Upon opening of the specimen, there is a 3.4- × 3.0-cm nodular mass. 36 lymph nodes were retrieved. Representative sections are submitted.Microscopic description: Microscopic examination performedSelect the appropriate ICD-10-CM and CPT code(s):