codegirl0422
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Can anyone help me with this note? I am new to urology and I am probably over thinking it but need some help. doctor put 52224 52204.
PREOPERATIVE DIAGNOSES: 1. Hematuria.
2. Flank pain.
3. History of adrenal adenoma.
POSTOPERATIVE DIAGNOSES: Renal mass based on retrograde, and based on CAT scan
there is an adrenal mass for sure, but there is also a mass in
the left kidney and there is a stone in the left upper ureter
evident.
PROCEDURE PERFORMED: 1. Cystoscopy.
2. Retrogrades.
3. Dilation.
4. Fulguration of bladder bleeders.
PROCEDURE: The patient was taken to the operating room, placed under anesthesia, then in dorsal
lithotomy position the area was prepped and draped in the usual fashion.
Genitalia examination showed: 1) normal labia; 2) urethral meatus is normal; 3) urethra is normal, no
diverticulum; 4) no pelvic mass; 5) no prolapse.
The urethra was calibrated barely to 16 French, dilated up to 28 French. A 23 scope was inserted in the
bladder which showed: 1) urethra showed normal findings: 2) mid urethra showed no diverticulum; 3)
proximal urethra is normal. The bladder was visualized which showed some nonspecific bleeding from
the lateral wall without any definite tumor evident to me. There were no papillary tumors, carcinoma in
situ, or diverticula. Examination was done in exemplary manner so we will not miss any diagnoses along
with examination of the dome of the bladder thoroughly and anterior neck. I did not see any tumors but
there was a suspicion of bleeding coming from the left kidney.
Right retrograde pyelogram was done, which showed evidence of normal ureterogram and caliceal system
showed some splaying in the upper portion of the kidney indicative of the possibility of lump. This was
then followed with a CAT scan which does show a round adenoma in the adrenal gland which may
require further evaluation and assessment in my opinion. On the left side there was no caliceal deformity
based on retrograde pyelogram but the follow-up CAT scan shows a mass in the retroperitoneum adjacent
to the kidney, which will require further evaluation with MRI in my opinion. The patient does understand
the importance of the same and is willing to proceed. I showed the CAT scan to her after surgery and
prior to taking her to Recovery I was able to fulgurate the bladder bleeding to reduce the risk of blood
loss.
PREOPERATIVE DIAGNOSES: 1. Hematuria.
2. Flank pain.
3. History of adrenal adenoma.
POSTOPERATIVE DIAGNOSES: Renal mass based on retrograde, and based on CAT scan
there is an adrenal mass for sure, but there is also a mass in
the left kidney and there is a stone in the left upper ureter
evident.
PROCEDURE PERFORMED: 1. Cystoscopy.
2. Retrogrades.
3. Dilation.
4. Fulguration of bladder bleeders.
PROCEDURE: The patient was taken to the operating room, placed under anesthesia, then in dorsal
lithotomy position the area was prepped and draped in the usual fashion.
Genitalia examination showed: 1) normal labia; 2) urethral meatus is normal; 3) urethra is normal, no
diverticulum; 4) no pelvic mass; 5) no prolapse.
The urethra was calibrated barely to 16 French, dilated up to 28 French. A 23 scope was inserted in the
bladder which showed: 1) urethra showed normal findings: 2) mid urethra showed no diverticulum; 3)
proximal urethra is normal. The bladder was visualized which showed some nonspecific bleeding from
the lateral wall without any definite tumor evident to me. There were no papillary tumors, carcinoma in
situ, or diverticula. Examination was done in exemplary manner so we will not miss any diagnoses along
with examination of the dome of the bladder thoroughly and anterior neck. I did not see any tumors but
there was a suspicion of bleeding coming from the left kidney.
Right retrograde pyelogram was done, which showed evidence of normal ureterogram and caliceal system
showed some splaying in the upper portion of the kidney indicative of the possibility of lump. This was
then followed with a CAT scan which does show a round adenoma in the adrenal gland which may
require further evaluation and assessment in my opinion. On the left side there was no caliceal deformity
based on retrograde pyelogram but the follow-up CAT scan shows a mass in the retroperitoneum adjacent
to the kidney, which will require further evaluation with MRI in my opinion. The patient does understand
the importance of the same and is willing to proceed. I showed the CAT scan to her after surgery and
prior to taking her to Recovery I was able to fulgurate the bladder bleeding to reduce the risk of blood
loss.
