Grasping a lot of these, but I am stumped on this one, Suggestions from any Podiatry gurus out there on how YOU would code this note.
TIA<
MJNB,CCS,CPC
Preoperative Diagnosis/es:
# 1 Malalignment syndrome, 1st MPJ , RIGHT
# 2 Metatarsus primus adductus, RIGHT
Postoperative Diagnosis/es:
-SAME
OPERATIONS Performed:
# 1 Osteotomy, proximal (closing base wedge), 1st metatarsal, , RIGHT
# 2 Bunionectomy with lateral soft tissue release,, RIGHT
>> Hallux, T5 (right 1st)
Anesthesia: General Anesthesia
Fluids: 500cc Lactated Ringers
Injectables:1:1 mix of Lidocaine 2% & Marcaine 0.5% (without epinephrine), 6 cc
Hemostasis (pneumatic tourniquet) :ankle, RIGHT At 250 mmHg
Tourniquet time: Right = 55 minutes
EBL: None
Pathology: none needed
Materials used:
>> Suture:4-0 biosyn and 3-0 polysorb
>> Fixation: Osteomed H plate with 2.7 screws, 14 x2, 16, 18, Threaded kwire - buried
PREPARATION:
> patient placed on operative table in supine and secured
> time out performed:
reconfirming patient identity, consented procedures and surgical sites
all members of the surgical team identified themselves
> padded pneumatic tourniquet applied to RIGHT
> after induction of anesthesia:
preoperative injectables applied
sterile prep and drape
>RIGHT raised, manually compressed, tourniquet inflated
OPERATION SUMMARY:
Incision: dorso-medial linear longitudinal from 1st metatarsal base to distal to 1st MPJ
Dissection; blunt/sharp to periosteal level, coagulating small venous structures as needed
-bluntly over 1st MPJ into first interspace where the insertion of the conjoined tendon was released from insertion into lateral aspect of fibular sesamoid and base of proximal phalanx
-dorso-medial linear longitudinal cut/reflection of periosteum exposing proximal base of 1st metatarsal
-axis k wire driven from dorsal to plantar, in medial cortex 15 mm from base, oriented perpedicular to the dorsa cortex of 1st metatarsal
-via osteotomy guide, a 4 mm lateral based transverse wedge cut/removed
-osseous hinge feather to close osteotomy which was pinned laterally with threaded kwire
-reduction of deformity and position of bone confirmed via fluoroscopy
-locking plate/screws applied medially, spanning the osteotomy - position confirmed via fluroscopy
-threaded kwire cut above cortex
-dorso-medial linear cut/reflection of capsule off medial 1st metatarsal head
-medial 1st metatarsal head prominence removed
-inspection: no further medial prominence of 1st metatarsal head, smooth ROM of 1st MPJ
Irrigation:
30 cc saline
Closure: capsule/periosteum with polysorb, skin with biosyn
Tourniquet: released, capillary refill returned to foot/digits
Dressing: steristrips, gauze, webril, coban
Patient tolerated procedure well
Awakened by anesthesia service
Taken to recovery
Post op instructions will be dispensed/reviewed
Follow up care scheduled at Podiatry Clinic
TIA<
MJNB,CCS,CPC
Preoperative Diagnosis/es:
# 1 Malalignment syndrome, 1st MPJ , RIGHT
# 2 Metatarsus primus adductus, RIGHT
Postoperative Diagnosis/es:
-SAME
OPERATIONS Performed:
# 1 Osteotomy, proximal (closing base wedge), 1st metatarsal, , RIGHT
# 2 Bunionectomy with lateral soft tissue release,, RIGHT
>> Hallux, T5 (right 1st)
Anesthesia: General Anesthesia
Fluids: 500cc Lactated Ringers
Injectables:1:1 mix of Lidocaine 2% & Marcaine 0.5% (without epinephrine), 6 cc
Hemostasis (pneumatic tourniquet) :ankle, RIGHT At 250 mmHg
Tourniquet time: Right = 55 minutes
EBL: None
Pathology: none needed
Materials used:
>> Suture:4-0 biosyn and 3-0 polysorb
>> Fixation: Osteomed H plate with 2.7 screws, 14 x2, 16, 18, Threaded kwire - buried
PREPARATION:
> patient placed on operative table in supine and secured
> time out performed:
reconfirming patient identity, consented procedures and surgical sites
all members of the surgical team identified themselves
> padded pneumatic tourniquet applied to RIGHT
> after induction of anesthesia:
preoperative injectables applied
sterile prep and drape
>RIGHT raised, manually compressed, tourniquet inflated
OPERATION SUMMARY:
Incision: dorso-medial linear longitudinal from 1st metatarsal base to distal to 1st MPJ
Dissection; blunt/sharp to periosteal level, coagulating small venous structures as needed
-bluntly over 1st MPJ into first interspace where the insertion of the conjoined tendon was released from insertion into lateral aspect of fibular sesamoid and base of proximal phalanx
-dorso-medial linear longitudinal cut/reflection of periosteum exposing proximal base of 1st metatarsal
-axis k wire driven from dorsal to plantar, in medial cortex 15 mm from base, oriented perpedicular to the dorsa cortex of 1st metatarsal
-via osteotomy guide, a 4 mm lateral based transverse wedge cut/removed
-osseous hinge feather to close osteotomy which was pinned laterally with threaded kwire
-reduction of deformity and position of bone confirmed via fluoroscopy
-locking plate/screws applied medially, spanning the osteotomy - position confirmed via fluroscopy
-threaded kwire cut above cortex
-dorso-medial linear cut/reflection of capsule off medial 1st metatarsal head
-medial 1st metatarsal head prominence removed
-inspection: no further medial prominence of 1st metatarsal head, smooth ROM of 1st MPJ
Irrigation:
30 cc saline
Closure: capsule/periosteum with polysorb, skin with biosyn
Tourniquet: released, capillary refill returned to foot/digits
Dressing: steristrips, gauze, webril, coban
Patient tolerated procedure well
Awakened by anesthesia service
Taken to recovery
Post op instructions will be dispensed/reviewed
Follow up care scheduled at Podiatry Clinic