Wiki Is there a better code than 43999

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New Palestine, Indiana
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30 minutes ago
PREOPERATIVE DIAGNOSIS:
Concern for gastrostomy tube granulation.
POSTOPERATIVE DIAGNOSIS:
Evidence of gastric prolapse mucosa.
PROCEDURE PERFORMED:
Revision of gastrostomy site with prolapsed gastric mucosa excision.
Final Report *
INDICATIONS:
2-1/2-year-old boy with longstanding use of a gastrostomy device, who presented to the outpatient clinic with notation of prolapsing tissue at the gastrostomy site. This had been repeatedly treated as an outpatient with silver nitrate by the parents and with its failed treatment was evaluated and felt that required surgical excision of the granulation tissue. The patient was initially evaluated by
Operative Note * Final Report *
Document Type: Document Subject: Performed By: Verified By: Encounter Info: PREOPERATIVE DIAGNOSIS:
Concern for gastrostomy tube granulation.
POSTOPERATIVE DIAGNOSIS:
Evidence of gastric prolapse mucosa.
PROCEDURE PERFORMED:
Revision of gastrostomy site with prolapsed gastric mucosa excision.
SURGEON:
Final Report *
INDICATIONS:
is a 2-1/2-year-old boy with longstanding use of a gastrostomy device, who presented to the outpatient clinic with notation of prolapsing tissue at the gastrostomy site. This had been repeatedly treated as an outpatient with silver nitrate by the parents and with its failed treatment was evaluated and felt that required surgical excision of the granulation tissue. The patient was initially evaluated by Dr. and case handed off for operative performance this evening.
DESCRIPTION OF PROCEDURE:
Following attainment of consent and explanation of risks and benefits associated with the procedure, the patient was taken to the operative suite on the evening of January 23rd. Per Anesthesia Service, IV access was obtained peripherally and the patient was placed under general anesthetic via laryngeal mask. The patient was maintained in supine position. The gastrostomy tube was decannulated. The abdomen was prepped with Betadine solution. Appropriate verification of the planned procedure and correct patient was verified preoperatively.
Upon inspection of the tissue, it appeared to be emanating from the gastric lumen. Inspection felt to be hyperplastic polypoid tissue of prolapsed gastric mucosa. Given the extensive nature of this, approximately 25% circumference was chosen to excise the associated prolapsed tissue and allowing for primary reapproximation of the gastric lining to the skin with interrupted 4-0 Vicryl suture. Remainder of the gastric polyps tissue was able to be directly reduced into the patient's stomach. Upon completion of this, the gastrostomy device was replaced into the abdominal cavity with 14- French x 1.7 cm MiniONE gastrostomy device. Split cover gauze dressing was applied to the gastrostomy device.
The patient was awoken per Anesthesia Service, extubated in the operative suite and taken to the postanesthesia care unit in stable condition.
DICTATED BY:

Dr. and case handed off for operative performance this evening.
DESCRIPTION OF PROCEDURE:
Following attainment of consent and explanation of risks and benefits associated with the procedure, the patient was taken to the operative suite on the evening of January 23rd. Per Anesthesia Service, IV access was obtained peripherally and the patient was placed under general anesthetic via laryngeal mask. The patient was maintained in supine position. The gastrostomy tube was decannulated. The abdomen was prepped with Betadine solution. Appropriate verification of the planned procedure and correct patient was verified preoperatively.
Upon inspection of the tissue, it appeared to be emanating from the gastric lumen. Inspection felt to be hyperplastic polypoid tissue of prolapsed gastric mucosa. Given the extensive nature of this, approximately 25% circumference was chosen to excise the associated prolapsed tissue and allowing for primary reapproximation of the gastric lining to the skin with interrupted 4-0 Vicryl suture. Remainder of the gastric polyps tissue was able to be directly reduced into the patient's stomach. Upon completion of this, the gastrostomy device was replaced into the abdominal cavity with 14- French x 1.7 cm MiniONE gastrostomy device. Split cover gauze dressing was applied to the gastrostomy device.
The patient was awoken per Anesthesia Service, extubated in the operative suite and taken to the postanesthesia care unit in stable condition.
 
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