Not sure how to code this. Physician performed an intraoperative exam. Urologist was called to OR after left hemiscrotum was noted to be enlarged and firm. Pt already under anesthesia undergoing lap hernia repair.
Findings: Left hemiscrotal exam shows either a large spermatocele or epididymal cyst. Testicle was felt to be most likely normal.
Procedure: PT was already under general anesthesia was urology entered the room. Lap equipment was in the abdomen and the hernia was examine laparoscopically. I then palpated the left hemiscrotum with finding stated above. I advised general surgeon that PT would need another ultrasound and most likely scrotal exploration which would be open and remove the mass or cyst.
Plan: Will see pt as an outpatient with scrotal ultrasound.
Findings: Left hemiscrotal exam shows either a large spermatocele or epididymal cyst. Testicle was felt to be most likely normal.
Procedure: PT was already under general anesthesia was urology entered the room. Lap equipment was in the abdomen and the hernia was examine laparoscopically. I then palpated the left hemiscrotum with finding stated above. I advised general surgeon that PT would need another ultrasound and most likely scrotal exploration which would be open and remove the mass or cyst.
Plan: Will see pt as an outpatient with scrotal ultrasound.