sheena91382
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I have a patient that came into the office to have her port-a-cath removed (36590,79) during her post-op period. After the port was pulled, bleeding would not stop. Physician called 911 & had patient transported to the hospital & taken directly into surgery. The op note follows:
Pre-Op Dx: emergent bleeding and hematoma of left chest wall port site.
Post-Op Dx: emergent bleeding and hematoma of left chest wall port site.
Procedure: evacuation of hematoma and ligation of bleeders
Brief note: the patient was brought over as an emergency due to inability to control bleeding in my office after removal of the port. Pressure was held on the way over and she was brought by ambulance and brought emergently directly to the operating room.
Procedure: After achievement of intervenous sedation, the patient was prepped with Betadine and draped in the usual sterile fashion. The port incision was enlarged and I carefully evaluated all four quadrants. There were two small bleeders at the medial aspect in the fatty tissue. There were ligated. Hematoma was evacuated. The incision was closed with two layers, one layer of Vicryl, one layer of Ethilon. Patient tolerated the procedure well and was returned to DOSA and discharged later same day. All counts correct at the end of the case.
Estimated Blood Loss: here was minimal. In the office was approximately 150ml.
Findings: as noted above.
We don't do vascular surgeries, so I'm completely out of my comfort zone on this one! Anyone have any suggestions?
I'm looking at the unlisted code 37799
Pre-Op Dx: emergent bleeding and hematoma of left chest wall port site.
Post-Op Dx: emergent bleeding and hematoma of left chest wall port site.
Procedure: evacuation of hematoma and ligation of bleeders
Brief note: the patient was brought over as an emergency due to inability to control bleeding in my office after removal of the port. Pressure was held on the way over and she was brought by ambulance and brought emergently directly to the operating room.
Procedure: After achievement of intervenous sedation, the patient was prepped with Betadine and draped in the usual sterile fashion. The port incision was enlarged and I carefully evaluated all four quadrants. There were two small bleeders at the medial aspect in the fatty tissue. There were ligated. Hematoma was evacuated. The incision was closed with two layers, one layer of Vicryl, one layer of Ethilon. Patient tolerated the procedure well and was returned to DOSA and discharged later same day. All counts correct at the end of the case.
Estimated Blood Loss: here was minimal. In the office was approximately 150ml.
Findings: as noted above.
We don't do vascular surgeries, so I'm completely out of my comfort zone on this one! Anyone have any suggestions?
I'm looking at the unlisted code 37799