slc112071
Networker
Could someone please help with coding the below report. I am having difficulties with this one.
The patient was brought to the operating room.
He was placed in supine position. He underwent endotracheal intubation and
general anesthesia. He was prepped and draped after appropriate preoperative
timeout and appropriate preoperative antibiotics. His right groin was incised
along the palpable masses seen on ultrasound.
Subcutaneous tissue was dissected and I started resecting these large masses
that were below the skin level in the subcutaneous tissue and I sent then to
pathology for frozen section and permanent.
I eventually found a hard mass on top of his right femoral artery and right
femoral vein and right femoral nerve. I continued to dissect that and I
removed the foreign bodies off of the right femoral vein and the right femoral
artery at the level of the right common femoral, right superficial femoral
artery and right profunda artery.
I sent that to pathology for frozen and permanent. Initial frozen showed some
bone formation with the foreign body. This is all likely a reaction to the
Mynx closure device.
I then repaired the right femoral vein with a 6-0 Prolene sutures. I repaired
the right superficial femoral artery, the right common femoral artery and the
right profunda arteries all with 5-0 Prolene sutures.
Prior to resecting off the artery to achieve proximal and distal control with
vessel loops, I gave 7500 units of heparin to achieve an ACT of 200.
Once I completed that there were still quite a bit of foreign body on the
right femoral nerve and I started to debride that and then I called Dr. B
my orthopedic colleagues to come and assist me and to get a formal opinion.
Dr. B came kindly and assessed the femoral nerve and talked to the family
with me and he debrided as much foreign body as possible off the right femoral
nerve and I assisted him with that part.
He will dictate a separate note with regards to the debridement of the right
femoral nerve.
At the end of the case we removed all foreign body; however, we felt we left
still a little bit on to the femoral nerve and we took risk versus reward. We
did not want to cause any permanent damage and decided to leave a little bit
of foreign body close to the right femoral nerve.
I then irrigated the wound extensively with a PulseTech and I closed it in
several layers of 2-0 Vicryl and skin with skin staples and placed a VAC on
the wound. I had good dopplerable pulses proximally and distally.
He was taken to the recovery room in stable condition. Sponge count and
instrument count were correct at the end of the case.
The patient was anesthetized and had been through
the portion of the procedure with Dr. M for the femoral artery and
femoral vein. Examination of the wound revealed a several centimeter
granulomatous tissue overlying the femoral nerve adjacent to the femoral
artery and femoral vein. I carefully dissected and found just deep to the
granuloma was the femoral nerve within its sheath. I carefully performed
dissection about the femoral nerve superficially and removed a several
centimeter piece of this granulomatous tissue, leaving the femoral nerve
proximally free of any reactive tissue. Distally the nerve was quite adherent
to the granulomatous tissue. An epineurotomy was performed in order to
attempt to remove this tissue; however, we could not get the tissue off of the
nerve and the concern was that any further dissection might injure the
specific nerve fibers. Therefore, a small rim perhaps 1-2 mm in depth was
left adherent to the epineurium of the femoral nerve distally. The nerve
appeared intact and normal; proximally it did as well. There is no
compression of the femoral nerve by the reactive tissue once we had finished
debriding. At this point, once the femoral nerve and dissected out and
cleaned to our best ability, I scrubbed out of the case and the closure was
left to Dr. M and his other assistant. Postoperatively the patient will
begin therapy slowly. We will check on his nerve status the next day. Other
postoperative details will be per Dr. M.
The patient was brought to the operating room.
He was placed in supine position. He underwent endotracheal intubation and
general anesthesia. He was prepped and draped after appropriate preoperative
timeout and appropriate preoperative antibiotics. His right groin was incised
along the palpable masses seen on ultrasound.
Subcutaneous tissue was dissected and I started resecting these large masses
that were below the skin level in the subcutaneous tissue and I sent then to
pathology for frozen section and permanent.
I eventually found a hard mass on top of his right femoral artery and right
femoral vein and right femoral nerve. I continued to dissect that and I
removed the foreign bodies off of the right femoral vein and the right femoral
artery at the level of the right common femoral, right superficial femoral
artery and right profunda artery.
I sent that to pathology for frozen and permanent. Initial frozen showed some
bone formation with the foreign body. This is all likely a reaction to the
Mynx closure device.
I then repaired the right femoral vein with a 6-0 Prolene sutures. I repaired
the right superficial femoral artery, the right common femoral artery and the
right profunda arteries all with 5-0 Prolene sutures.
Prior to resecting off the artery to achieve proximal and distal control with
vessel loops, I gave 7500 units of heparin to achieve an ACT of 200.
Once I completed that there were still quite a bit of foreign body on the
right femoral nerve and I started to debride that and then I called Dr. B
my orthopedic colleagues to come and assist me and to get a formal opinion.
Dr. B came kindly and assessed the femoral nerve and talked to the family
with me and he debrided as much foreign body as possible off the right femoral
nerve and I assisted him with that part.
He will dictate a separate note with regards to the debridement of the right
femoral nerve.
At the end of the case we removed all foreign body; however, we felt we left
still a little bit on to the femoral nerve and we took risk versus reward. We
did not want to cause any permanent damage and decided to leave a little bit
of foreign body close to the right femoral nerve.
I then irrigated the wound extensively with a PulseTech and I closed it in
several layers of 2-0 Vicryl and skin with skin staples and placed a VAC on
the wound. I had good dopplerable pulses proximally and distally.
He was taken to the recovery room in stable condition. Sponge count and
instrument count were correct at the end of the case.
The patient was anesthetized and had been through
the portion of the procedure with Dr. M for the femoral artery and
femoral vein. Examination of the wound revealed a several centimeter
granulomatous tissue overlying the femoral nerve adjacent to the femoral
artery and femoral vein. I carefully dissected and found just deep to the
granuloma was the femoral nerve within its sheath. I carefully performed
dissection about the femoral nerve superficially and removed a several
centimeter piece of this granulomatous tissue, leaving the femoral nerve
proximally free of any reactive tissue. Distally the nerve was quite adherent
to the granulomatous tissue. An epineurotomy was performed in order to
attempt to remove this tissue; however, we could not get the tissue off of the
nerve and the concern was that any further dissection might injure the
specific nerve fibers. Therefore, a small rim perhaps 1-2 mm in depth was
left adherent to the epineurium of the femoral nerve distally. The nerve
appeared intact and normal; proximally it did as well. There is no
compression of the femoral nerve by the reactive tissue once we had finished
debriding. At this point, once the femoral nerve and dissected out and
cleaned to our best ability, I scrubbed out of the case and the closure was
left to Dr. M and his other assistant. Postoperatively the patient will
begin therapy slowly. We will check on his nerve status the next day. Other
postoperative details will be per Dr. M.