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Howdo you tell the diagnosis on this case ? Want tojust use dx as 836.0 ,isthiscorrect /
PREOPERATIVE DIAGNOSIS: Internal derangement, left knee.
POSTOPERATIVE DIAGNOSIS: Left knee medial meniscus tear.
PROCEDURE PERFORMED: Left knee arthroscopy, partial medial meniscectomy (CPT code 29881).
CLINICAL HISTORY: . patient has underlying degenerative change, but with mechanical symptoms after having the meniscal tear, was brought to the operating room for above procedure. Complications, recurrence, infection, and numbness, stiffness, and implication of degenerative change and meniscal tearing and postoperatively rehab involvement _____(00:38) DVT were all discussed. Informed consent was obtained.
OPERATIVE PROCEDURE: The patient was brought into the operating room, placed supine on the OR table with general laryngeal mask anesthesia. Her limb was prepped and draped in a standard fashion. Exam under anesthesia showed a minor effusion and no instability. The limb was in the arthroscopic leg holder and tourniquet on the thigh. Esmarch and tourniquet inflated to 300. Incision was made distal to the patellar tendon medial and lateral, superomedial and inferolateral portal. The scope was introduced through the inferolateral portal. The patellofemoral joint had some minor grade II fraying. There was cartilage debris floating within the suprapatellar pouch. It was evacuated with a shaver. The gutters were normal. Medial compartment had a radial-type tear in the medial meniscus. This was debrided back to stable cartilage with basket forceps and motorized shaver. The articular cartilage on the medial side showed some minor grade II fraying on both the femur and the tibia without need for a debridement. The notch showed normal ACL and PCL. The lateral compartment was normal. The scope was returned to the suprapatellar pouch where the meniscal fragments were removed with shaver and completed the case. The portal sites were infiltrated with Marcaine, closed with nylon suture. The knee was infiltrated with Marcaine as well, about 10 cc. Sterile dressings were placed. Tourniquet was deflated briefly following procedure. The patient was extubated and taken to recovery room in stable condition. Blood loss was minimal. Sponge, lap, and needle counts were all correct. No complications.
PREOPERATIVE DIAGNOSIS: Internal derangement, left knee.
POSTOPERATIVE DIAGNOSIS: Left knee medial meniscus tear.
PROCEDURE PERFORMED: Left knee arthroscopy, partial medial meniscectomy (CPT code 29881).
CLINICAL HISTORY: . patient has underlying degenerative change, but with mechanical symptoms after having the meniscal tear, was brought to the operating room for above procedure. Complications, recurrence, infection, and numbness, stiffness, and implication of degenerative change and meniscal tearing and postoperatively rehab involvement _____(00:38) DVT were all discussed. Informed consent was obtained.
OPERATIVE PROCEDURE: The patient was brought into the operating room, placed supine on the OR table with general laryngeal mask anesthesia. Her limb was prepped and draped in a standard fashion. Exam under anesthesia showed a minor effusion and no instability. The limb was in the arthroscopic leg holder and tourniquet on the thigh. Esmarch and tourniquet inflated to 300. Incision was made distal to the patellar tendon medial and lateral, superomedial and inferolateral portal. The scope was introduced through the inferolateral portal. The patellofemoral joint had some minor grade II fraying. There was cartilage debris floating within the suprapatellar pouch. It was evacuated with a shaver. The gutters were normal. Medial compartment had a radial-type tear in the medial meniscus. This was debrided back to stable cartilage with basket forceps and motorized shaver. The articular cartilage on the medial side showed some minor grade II fraying on both the femur and the tibia without need for a debridement. The notch showed normal ACL and PCL. The lateral compartment was normal. The scope was returned to the suprapatellar pouch where the meniscal fragments were removed with shaver and completed the case. The portal sites were infiltrated with Marcaine, closed with nylon suture. The knee was infiltrated with Marcaine as well, about 10 cc. Sterile dressings were placed. Tourniquet was deflated briefly following procedure. The patient was extubated and taken to recovery room in stable condition. Blood loss was minimal. Sponge, lap, and needle counts were all correct. No complications.