Question

7.32. Discharge Summary

Admission Date: November 15, 20XX

Discharge Date: November 20, 20XX

Description: The patient is a 49-year-old male who was admitted on November 15. He underwent revision laminectomy and stabilization of his lumbar spine with a Dynesys system. The patient tolerated the procedure well and had an uneventful hospital course, except experienced acute pain after the surgery requiring additional physical therapy and pain control. By postoperative day 5, he was tolerating a regular diet, had obtained pain control, and cleared physical therapy. He was subsequently discharged home with written instructions. He is to follow up in 3 weeks after discharge. He was given Percocet and Flexeril for pain and spasms, as needed.

History and Physical

Admit Diagnosis: Recurrent herniated disc

Procedure: Lumbar laminectomy, disc stabilization with Dynesys

History of Present Illness: 49-year-old male with left leg and back pain. Diagnosed with recurrent disc herniation

Past Medical History: Status post laminectomy and diskectomy 2 years ago

Physical Examination

Neck: Supple

Heart: Regular rate and rhythm

Lungs: Clear to auscultation

Neuro: Left leg weakness, numbness, and pain

Skin: No lesions, masses, or rashes

Assessment and Plan: Recurrent HNP LS to S 1

Operative Report

Preoperative Diagnosis: Radiculopathy and degenerative disc disease at LS-S 1 with recurrent disc herniation at LS-S 1

Postoperative Diagnosis: Same

Procedure Performed: Revision LS laminectomy, revision S 1 laminectomy and diskectomy, stabilization of LS to S 1 with flexible rod Dynesys system

Anesthesia: General

Blood Loss: Minimal

Complications: Intraoperative dural tear, which was repaired with watertight seal with interrupted 4-0 Nurolon sutures

Description of the Procedure: Under sterile conditions, the patient was brought to the operating room and was placed under general endotracheal anesthesia and placed in a prone position. Lumbar spine was then prepped and draped in the usual sterile manner with a Betadine prep. A lateral x-ray was obtained with an 18-gauge spinal needle placed for level localization. Based upon the x-ray, a direct posterior approach to the lumbar spine was performed. This was carried down to the transverse process of L5 and the sacral ala bilaterally. After adequate exposure, complete laminectomy was performed in a subperiosteal fashion with a combination Leksell and Kerrison rongeurs at the LS and S 1 levels. Mobilization of the left S 1 and L5 nerve roots was performed, although there was a significant amount of scar tissue. There was a large free LS-S 1 recurrent disc fragment, which was removed with a pituitary rongeur. There was a small dural tear within the axilla of the L5 nerve root repaired with watertight seal with intenupted 4-0 Nurolon sutures. After adequate decompression, attention was brought to stabilization. Using the usual internal and external landmarks, pedicle screws were placed in the L5 and Sl pedicles bilaterally. These were drilled, probed, dilated, and then a combination of 7.2 mm x 40 mm screws and 7.2 mm x 45 mm screws were placed in the L5 and S 1 pedicles bilaterally. AP and lateral x-rays were obtained, noting appropriate placement of the screws. Measuring of the cord device was performed bilaterally. The cord was placed in the usual fashion, tensioned, and then finally tightened. The wound was copiously irrigated with bacitracin solution. No drain was utilized. The fascia was closed with intenupted 0 VICRYL suture. The subcutaneous tissue and skin were closed in three sequential layers. The patient was awakened in the operating room, extubated, and brought to the recovery room in satisfactory condition.

Are these codes correct? 722.10; 338.12, 349.31, 722.52, E870.0, 80.51, 84.82, 03.59

7.33. Discharge Summary

Date of Admission: 2/3

Date of Discharge: 2/4

Discharge Diagnosis: Malignant ascites from metastatic adenocarcinoma of the colon

Course in Hospital: This 59-year-old white female patient was admitted for continuous infusion chemotherapy with 5-FU and Leucovoran. This was done under the care of Dr. ZXY. The patient tolerated her chemotherapy very well. She had no complications throughout her hospital course, and she was discharged to be followed further as an outpatient by her oncologist.

Instructions on Discharge: Follow up in the office

History and Physical

Admitted: 2/3/20XX

Reason for Admission: Chemotherapy

History of Present Illness: The patient is a 59-year-old white female with peritoneal carcinomatosis and malignant ascites from colon carcinoma. She is admitted for continuous chemotherapy. The patient has a sigmoid colostomy and has had multiple abdominal surgeries for carcinoma; the first one was an anterior and posterior repair in 1982. She had six weeks of radiation therapy completed two years ago and has been on weekly chemotherapy consisting of 5-FU and methotrexate recently. Because of increasing abdominal girth, she was admitted in June and diagnosed with malignant ascites and carcinomatosis. At that time, she had an extensive evaluation including an upper gastrointestinal series, barium enema, CT scan, and ultrasound of the abdomen. She was told she had adhesions causing a partial obstruction. No further surgery was pursued. For the past week, she has complained of frequent vomiting. Her weight has decreased another six pounds. She denies any abdominal pain. She has occasional diarrhea for which she takes Questran. She has had no blood in her colostomy drainage.

Past Medical History: No hypertension, myocardial infarction, diabetes, or peptic ulcer disease. Anterior and posterior repair in 1982, colectomy, cholecystectomy, appendectomy, hysterectomy with bilateral salpingo-oophorectomy for uterine fibroids in 1968.

Allergies: None

Chronic Medications: Pancrease three times a day; Questran as needed for diarrhea; Os-Cal 2x a day, 250 mg

Family History: Mother died at age 80. Father died of colon cancer at age 60.

Social History: Prior to that time, she smoked a pack a day for 20 years. She denies any alcohol intake. She works in the shipping department.

Review of Systems: Unremarkable

Physical Examination: An alert, white female in no acute distress

General Appearance

Skin, Head, Eyes, Ears, Nose, Throat: Pupils are equal, reactive to light and accommodation. Extraocular movements are intact. Fundi are benign. Tympanic membranes are normal.

Mouth: No oral lesions are seen.

HEENT: Within normal limits

Neck: Carotids are plus 2 with no bruits. Thyroid is normal. There is no adenopathy at present.

Lungs: Clear

Heart: Regular sinus rhythm. No murmur, rub, or gallop.

Breasts: A small, approximately 3-mm, cystic lesion the medial aspect of her left breast at around eight o'clock. It is freely movable and nontender. There are no axillary nodes.

Abdomen: Distended. Sigmoid colostomy present. Right lower quadrant induration is present. There is no abdominal tenderness. There is no hepatosplenomegaly. Bowel sounds are normal.

Pulses: Femorals are plus 2 with no bruits. There are good pedal pulses bilaterally.

Genitalia: Normal

Rectal: Deferred

Extremities: No edema

Neurologic: Deep tendon reflexes are plus 2 throughout

Laboratory Data: Pending

Impression

Peritoneal carcinomatosis from colon cancer

Small left breast cyst

Plan: The patient will be admitted for continuous chemotherapy.

Progress Notes

2/3         Patient tolerating chemo well. No complaints offered.

2/4         Patient well hydrated, nausea and vomiting under control. Will discharge.

Are these codes correct? 197.6, 789.51, 789.51, V10.05, V44.3, V16.0, V15.3, V15.82, 38.93, 99.25

Answer 1

Answer for 7.32:

722.10 lumbar displacement
338.12 acute post thoracotomy pain
349.31 laceration of dura
722.52 degeneration of lumbar
E870.0 accidental cut, puncture, perforation or hemorrhage during surgery
80.51 excision of interverterbral disc
84.82 spinal stabilization device
03.59 repair of spinal meninges

Answer for 7.33:
197.6 secondary malignant neoplasm of retroperitoneum and peritoneum
789.51 malignant ascites
V10.05 malignant neoplasm of large intestine
V44.3 colostomy
V16.0 malignant neoplasm of digestive organs
V15.3 history of irradiation
V15.82 history of tobacco use
38.93 venous catheterization
99.25 chemotherapy