Tag Archives: Operative Notes

Operative Note Practice Scenario – 10

An esophagogastroduodenoscopy was performed with balloon dilation to open an esophageal stricture. After three attempts, the balloon dilation was unsuccessful. Jumbo biopsy forceps were then used to remove a section of the scarred stricture to create a wedge and prevent the stricture from constricting the esophageal lumen.

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Operative Note Practice Scenario – 9

The patient had a persistent left lung infiltrate on X-ray and subsequently had left pleural effusion. Thoracentesis and bronchoscopy with brush biopsy of the lung were performed. Tissue studies yielded no diagnosis. The patient was to be admitted for further evaluation.

Diagnosis: Left pleural infiltrate on X-ray, pleural effusion.

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Operative Note Practice Scenario – 8

The patient was brought in for surgical intervention of a mature, symptomatic cataract in the left eye and high intraocular pressures despite medical therapy. Procedures performed were an external trabeculectomy and phacoemulsification with posterior chamber intraocular lens placement.

Discharge diagnoses: (1) Advanced primary open-angle glaucoma, severe stage, (2) cataract, left eye.

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Operative Note Practice Scenario – 7

Preoperative diagnoses: Rhegm atogenous retinal detachment and nuclear sclerotic cataract, both to the right eye.

Name of Procedures: A 25-gauge pars plana vitrectomy, retinal detachment repair, air fluid exchange, air gas exchange with SF6 24%, indirect ophthalmoscope-delivered laser, all to the right eye.

Description of Procedure: The patient was seen in the pre-operative holding area and all questions about the procedure answered. Right eye was identified as the correct operative site and informed consent was confirmed. The patient was rolled in the supine position to the operative suite where appropriate cardiac and pulmonary monitoring devices were applied per anesthesia. The patient was placed under general anesthesia without complication. Right eye was prepped and draped in normal sterile fashion. Sterile lid speculum was placed. A standard 3-port 25-guage vitrectomy unit was used after placing the infusion cannula 4 mm posterior to the infratemporal limbus. Correct position was visualized before turning it on. Additional 2 ports were placed without complication. Initial vitrectomy was performed and carried out into the periphery with the aid of scleral depression. A posterior vitreous detachment was already present. The retinal detachment extended from 12 o’clock temporally down to 6:30 o’clock. Directly temporally there was an old demarcation line with a small horseshoe retinal tear in the middle near the aura. This was trimmed free from vitreous. A drainage retinotomy was then created along the superior temporal arcade with electric diathermy. Air fluid exchange was then performed with drainage of subretinal fluid using a 25-guage backflush cannula. The retina was seen to lay flat. Plugs were placed and indirect ophthalmoscope was used to place laser retinopexy around the retinotomy site, the previously marked retinal hole and in a 360 degree retinopexy fashion. Drainage was performed one more time before placing SF6 24% into the posterior segment. Sclerotomy ports were removed in sequential fashion. All wounds were found to be airtight. The patient was given subconjunctival injections of Ancef and Decadron. A sterile led speculum was removed. A light pressure patch was placed. The patient was taken to recovery room in stable condition after being awakened form general anesthesia in stable condition. He was to remain face down overnight and follow up tomorrow for post-operative exam and instructions.

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Operative Note Practice Scenario – 6

Pre-operative diagnosis: Right knee medial meniscus tear

Post-operative diagnosis:

  1. Right knee medial meniscus tear
  2. Right knee lateral meniscus tear
  3. Tricompartmental arthritis of the knee

Name of Procedure: Video arthroscopy of right knee with arthroscopic partial medial and lateral meniscectomies and chondroplasty.

Description of Procedure: Once consent was obtained, the patient was brought to the operating theater and placed on the operating room table in the supine position. Following smooth induction of general anesthesia, a tourniquet was placed around the patient’s right thigh. The right lower extremity was then prepped and draped in the usual sterile orthopedic fashion. The extremity was elevated and exsanguinated and tourniquet was inflated. A superomedial portal was made as an outflow portal and a cannula was introduced in the knee. An anterolateral portal was made and the camera was placed in the knee. Upon inspecting the knee the patient was noted to have a large amount of synovitis throughout the knee. The patellofemoral joint was first visualized. The patient had outerbridge grade 3, fraying of the patella and 2 of the trochlea. There was some fraying of the cartilage there. The camera was then passed around the medial femoral condyle to the medial compartment of the knee. The patient had a grade 3 wear involving the entire medial femoral condyle and some of the tibial condyle as well. However, he did have a large complex fragmented tear of the posterior horn of the medial meniscus. The arthroscopic portal was made after localizing it with a spinal needle. Using a combination of biters, the shaver and the ArthroCare wand, the posterior horn of the medial meniscus was debrided to a stable base. The medial meniscus was sealed with ArthroCare wand to prevent further fraying. Next, the notch was visualized and the ACL was inspected. The ACL was intact. The knee was placed into a figure 4 position and the lateral compartment was visualized. The lateral femoral condyle was intact. However, there was some grade 2 wear of the lateral tibial plateau. The patient did have a tear of the lateral meniscus as well. This was debrided with the biter and the shaver. The knee was then extended and a chondroplasty of the patellofemoral joint was performed using the shaver. The free edge of the fibrillations was debrided to prevent any further fraying or breakdown of the articular cartilage. The instruments were then removed. The wound was infiltrated with Marcaine for postoperative analgesia and the arthroscopic portals were closed primarily with 4-0 Monocryl. Anesthesia was then reversed and the patient was awakened and taken to recovery room in stable condition

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Operative Note Practice Scenario – 5

Pre-operative diagnosis: Lipoma of right upper arm

Post-operative diagnosis: Lipoma of right upper arm

Name of procedure: Excision of lipoma from right upper arm with layered closure of 6 cm incision.

Indications: The patient is a 70 year-old female who has a mass on the upper right arm which has been present for several years and has slowly increased in size. She now comes in for elective resection.

Description of Procedure: The patient was taken to the operating room and placed in the supine position on the operating room table. The right arm was supported on a pillow and secured to the bed. The skin overlying the mass of the upper arm was prepped with Betadine and then draped in sterile fashion. The skin overlying the mass was then anesthetized with 1% lidocaine with epinephrine. A transverse 6 cm incision was made. Subcutaneous tissue was divided with electocautery down through subcutaneous fat until the capsule of the lipoma could be identified. The lipoma was then easily dissected free from all surrounding tissue. There was a feeder vessel exiting the deltoid muscle beneath it. This was treated with electrocautery. The mass was removed intact without problems and appeared to be a typical lipoma. The wound was inspected for hemostasis and with this assured, the subdermal tissues were closed with interrupted 3-0 Vicryl and the skin was closed with a running subcuticular stitch of 5-0 Monocryl. Steri-Strips, Telfa and Tegadem dressings were applied. The patient tolerated the procedure very well and was able to ambulate from the minor surgery room without difficulty.

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Operative Note Practice Scenario – 4

Pre-operative Diagnosis: Breast Cancer, Need for Chemotherapy

Post-operative Diagnosis: Same

Procedure Performed: Insertion of Infusaport

This 65-year-old patient was taken to the operation room and placed supine on the OR table. After adequate sedation, the area of the anterior chest and neck were prepped and draped in sterile fashion. Access to the right subclavian vein was done in posterior fashion, and the wire was visualized under fluoroscopy to be in the right atrium. A pocket was made on the lateral aspect of the right clavicle, and the pocket was developed. The catheter was guided from the site of the pocket to the exit site of the wire. The dilator and sheath were placed over the wire and the dilator and wire were both removed. The catheter was immediately inserted into the sheath. The sheath was separated and removed. The tip was pulled back to the superior vena cava/right atrial junction. The catheter was cut to length at the pocket site and attached to the Infusaport with the connector in a steadfast fashion. The port was placed in the pocket and anchored to the chest wall with 3-0 nylon sutures that were placed to immobilize ad anchor the port. Then antibiotic irrigation was done. The port was tested, and it flushed back blood and flushed heparinized saline without occurrence. The subcutaneous tissue and subcuticular tissue were reapproximated with 4-0 Vicryl suture in a running fashion. Steri-Strips and a sterile dressing were applied. The patient tolerated the procedure well.

The patient was sent for a post-operative chest x-ray.

Chest x-ray single view findings: Single view was taken of the chest in frontal position. This demonstrates proper placement of the catheter tip in the right atrium. No other findings.

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Operative Note Practice Scenario – 3

Preoperative Diagnosis: Hematuria

Postoperative Diagnosis: Right Ureter Stone

Procedure Performed: Cystoscopy with Bilateral RPG, Right Ureteroscopy, and Stent placement. The patient was taken to the cystoscopy room, placed in the dorsolithotomy position, surgical site prepped and draped in the usual fashion. Following general anesthesia, rigid cystoscopy was performed with video guidance. Bladder was viewed in all quadrants without findings of foreign body, tumor or stone, normal ureteral orifice, bladder neck, and urethra. Right RPG was performed with open-ended catheter and a defect was seen in the mid ureter. There was no filing defect or obstruction seen in the remainder of the ureter. The left-sided RPG was performed, and no significant obstruction or filling defect was noted. Guidewire was passed in the right renal pelvis, adjacent to this, rigid ureteroscope was passed and the stone was encountered. The stone was removed with the basket forceps. The ureteroscope was then passed to the level of the iliacs without further stones being encountered. The ureteroscope was removed. 7 French x 26 centimeter double J stent was then placed, position was confirmed with fluoroscopy and procedure was terminated.

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Operative Note Practice Scenario -2

DOWNLOADABLE CPC®PRACTICE EXAM QUESTIONS

Name of Procedure: Colonoscopy

Pre-operative diagnosis: Screening exam

Post-operative diagnosis: A 1 x 1cm flat polyp at the mid ascending colon.

Description of Procedure: With MAC sedation, colonoscope introduced through the anus all the way to the cecum. The colon was somewhat elongated and I was able to pass the scope to the cecum by placing the patient on her back. The prep was not optimal. Examining the colon revealed 1 x 1 cm flat polyp on a colonic fold in the mid ascending colon. Several biopsies were obtained and then using the hot biopsy forceps, the polyp was fulgurated. Some bleeding was encountered, so 1 mL of 1: 10,000 epinephrine injected in the base of the fulgurated polyp, which stopped the bleeding. The rest of the colon was within normal limits. Rectal and anal exams were normal.  The patient tolerated the procedure well and was sent to the recovery room in good condition.

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Operative Note Practice Scenario -1

DOWNLOADABLE CPC®PRACTICE EXAM QUESTIONS

Pre-operative diagnoses: Lumbar spinal stenosis L3-4 and L4-5 with a grade 1 anterolisthesis L4 on 5.

Post-operative diagnoses: Lumbar spinal stenosis L3-4 and L4-5 with a grade 1 anterolisthesis L4 on 5.

Name of Procedure: Decompressive lumbar laminectomy L3 and L4 with microscopic decompression of L3, L4, and L5 nerve roots bilaterally.

Findings: Grade 1 anterolisthesis of L4 on 5 was present with significant spinal stenosis present here. Ligamentum flavum hypertrophy and facet joint overgrowth was present. In addition, the L3-4 level also showed ligamentum flavum and facet joint enlargement. Decompression of the thecal sac at both levels with the exiting 6 nerve roots performed.

Description of Procedure: The patient had endotracheal tube placed and general anesthetic administered. Pneumatic compression stockings were placed on the lower extremities. The patient was placed in the Andrews lumbar spinal frame in the kneeling position. Chest roll was placed. Care was taken to ensure that the extremities were properly padded and positioned and the abdomen and breasts were free of compression. A surgical pause was taken with the patient and the appropriate surgical site was identified. The patient’s lumbosacral area was prepped with Dura Prep and draped to a sterile field. Xylocaine 1% with epinephrine used to locally infiltrate the skin in the midline over the spinous processes of L3-L5. A midline incision was accomplished and carried down through the subcutaneous tissues. Dorsal lumbar fascia incised in the midline and subperiosteal elevation of the paravertebral musculature accomplished bilaterally. Intra-operative x-ray obtained with a marker on the spinous process of L4. Self-retaining cerebellar retractors placed. The spinous processes and lamina of L3 and L4 were removed using Adson rongeurs, angled Kerrison punches and high-speed Stryker drill. Operating microscope utilized to complete that laminectomy and to decompress the L3, L4, L5 nerve roots and the lateral recesses, as well as performing foraminotomies over the individual 6 nerve roots. Two mm Kerrison utilized to decompress each of the nerve roots with care taken to undercut the facet joints and prevent further instability. Double-ended ball hook could be passed out over each of the nerve roots at the conclusion of the procedure. Hemostasis obtained using Malis bipolar cautery and thrombin soaked pledgets Gelfoam. The wound was irrigated with saline. All micropatties, sponges and instruments were removed from the wound. Hemovac drain placed in the epidural space, brought out through a separate stab wound incision in the back and connected to closed drainage suction. The closure then accomplished in layers using interrupted 2-0 Vicryl suture on the muscle and fascial layers, interrupted 3-0 Vicryl suture on the subcutaneous tissues and a running 3-0 Vicryl subcuticular stitch utilized to approximate the skin edges along with Steri-Strips. Telfa and Op-Site dressings were placed. The patient was then awakened, extubated, and transported to the recovery room in stable condition.

Replacement: With crystalloid only.