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Date:01/07/2024 14:32 Author:Kenneth Wong, MD Location:General Hospital Title:Discharge Summary: Lumbar Laminectomy Note:FINAL DIAGNOSES: 1. Herniated nucleuses pulposus, L4-5 greater than L5-6, left greater than right with left L4-5 radiculopathy. 2. Moderate stenosis L5-6. OPERATION: Lumbar Laminectomy of L4-5 using Bengal cages and Slimlock plate L4 to L7; intraoperative x-ray. This is a white male who was in the office because of low back pain with left radiculopathy to the hip and leg. In the last year or so, he has had more and more difficulty and more recently has developed tingling and numbness into the leg and foot, left greater than right. He has some foot pain at times and has seen for an epidural steroid injection, which was very helpful. lumbar MRI scan was obtained and revealed a large right-sided disc herniation at L4-5 with significant midline herniations at L5-6 and a large left HNP at L6- 7. In view of the multiple levels of pathology, I was not confident that anything short of surgical intervention would give him significant relief. The procedure and its risk were fully discussed and he decided to proceed with the operation. HOSPITAL COURSE: Following admission, the procedure was carried out without difficulty. Blood loss was about 125 cc. Postop x-ray showed good alignment and positioning of the cages, plate, and screws. After surgery, he was able to slowly increase his activity level with assistance from physical therapy. He had some muscle spasms and soreness in his low back part. He also had some nausea with the Morphine. By the end of today, he was ready to go home. He has been counseled regarding wound care and has received a discharge sheet for instruction. Rehab has been in, assessed and made recommendations. Patient will begin therapy with 3x/week. He will be seen in two weeks for wound check to remove staples and for a followup evaluation/x-rays in about six weeks. He has prescriptions for Lortab 7.5 mg and Robaxin 750 mg. He is to call if there are any problems. PATIENT NAME: PATIENT TYPE (highlight the appropriate patient type for this case) : IP OP ED PHYSICIAN Practice If Inpatient, what is the patient’s Principal Diagnosis in words, followed by the ICD-10 code? If inpatient, what is/are the patient’s secondary diagnosis(es) (if any) in words, followed by the corresponding ICD code(s). You are responsible for knowing and understanding the definition of a secondary diagnosis that needs to be coded as well as sequencing guidelines. What is/are the corresponding ICD- code(s) for the diagnosis(es) If inpatient, what is the patient’s principal procedure in words, followed by the ICD code? If inpatient, what is/are the patient’s secondary procedure(s) (if any) in words, followed by the corresponding ICD code(s)? You are responsible for knowing and understanding the definition of a secondary procedures that need to be coded as well as sequencing guidelines. If Outpatient/ED/Physician practice what is the patient’s Primary Diagnosis in words, followed by the ICD code? Are there any secondary diagnosis(es) (if any) in words that should be coded? You are responsible for knowing and understanding the definition of a secondary diagnosis that needs to be coded as well as sequencing guidelines. What is/are the corresponding ICD code(s) for the diagnosis(es). Are there any procedures that need to be coded; if so, code them in the proper order, using the proper coding system. TYPE, IN PROPER ORDER, THE DIAGNOSIS AND PROCEDURE CODE(s) for CASE 4 are:
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