TammyHF
Guru
How would you code this:
?Brief operative note free text:
Male cystoscopy with difficult catheter placement over Glidewire:
Procedure:
The patient was brought into the procedure room. Informed written consent was obtained. He placed supine on the procedure table and prepped after removal of his Foley catheter. The flexible 16-French cystoscope was introduced per urethra into the bladder. The bladder was evaluated systematically. The Glidewire was passed through the scope into the bladder and then the bladder was backloaded off the guidewire. A 20 French council tip catheter was created and then passed over the Glidewire into the bladder with return of clear yellow urine. 10 cc of sterile water was used to inflate the catheter balloon.
Findings:
The anterior urethra is normal without strictures. The external urethral sphincter is fairly normal with a false passage in the right prostate floor, stable compared to previous. The prostate is mildly enlarged with bladder neck open. The bladder is 1-2+ trabeculated throughout with mild patchy erythema in the posterior bladder wall but no tumors or stones. Ureteral orifices were normal.
Patient tolerated the procedure without complication and was given a single dose of antibiotic for post procedure prophylaxis ? Cipro 500mg?
Only diagnoses patient has is a extremely large false passage and a neurogenic bladder.
?Brief operative note free text:
Male cystoscopy with difficult catheter placement over Glidewire:
Procedure:
The patient was brought into the procedure room. Informed written consent was obtained. He placed supine on the procedure table and prepped after removal of his Foley catheter. The flexible 16-French cystoscope was introduced per urethra into the bladder. The bladder was evaluated systematically. The Glidewire was passed through the scope into the bladder and then the bladder was backloaded off the guidewire. A 20 French council tip catheter was created and then passed over the Glidewire into the bladder with return of clear yellow urine. 10 cc of sterile water was used to inflate the catheter balloon.
Findings:
The anterior urethra is normal without strictures. The external urethral sphincter is fairly normal with a false passage in the right prostate floor, stable compared to previous. The prostate is mildly enlarged with bladder neck open. The bladder is 1-2+ trabeculated throughout with mild patchy erythema in the posterior bladder wall but no tumors or stones. Ureteral orifices were normal.
Patient tolerated the procedure without complication and was given a single dose of antibiotic for post procedure prophylaxis ? Cipro 500mg?
Only diagnoses patient has is a extremely large false passage and a neurogenic bladder.