How to Answer History Patient Taken Questions (Complete Guide)

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Original Question

History: The patient was taken to the operating suite and placed in the supine positioning. General anesthesia was obtained. The left shoulder and neck region was then properly prepped and draped in the usual sterile fashion. A timeout was done. Around 10cc of local anesthesia, ½ % Marcaine with epi, was injected 2 fingerbreadths below the curve of the left clavicle. The left subclavian vein was then accessed with an introducer needle. A flashback of venous blood was visualized in the syringe. The syringe was removed. The guidewire was then inserted and advanced with no difficulty. The guidewire was then fixed to the drape. A 3-4cm linear incision was then made on the left chest wall. Electrocautery was used to control hemostasis and dissect down through the subcutaneous tissues down to the anterior pectoralis fascia. An inferior pocket was created. The Mediport was then inserted into the pocket and sutured into place utilizing 2-0 nylon stitches. The catheter extending from the Mediport hub was then measured and trimmed to 17 cm in length. The dilator and peel-away sheath were then passed over the guidewire. After advancement, the dilator and wire was removed and the catheter was inserted into the sheath. The sheath was then peeled away and pressure was held. The catheter tip was noted to be in the area of the left superior vena cava with fluoroscopy. The port was aspirated with excellent return of blood and flushed without difficulty. The incisions were then closed with 3-0 Vicryl suture in the deep layer and 4-0 Vicryl in a running subcuticular fashion in the skin. Dermabond was then used, and the patient tolerated the procedure well and was sent to the recovery room in stable condition. A postop chest x-ray was obtained and showed no pneumothorax and good positioning of the port. Description of Procedure: Following satisfactory general endotracheal anesthesia, the patient was positioned, prepped and draped in the usual manner. Medial and lateral incisions were made from the groin almost down to the knee in the right thigh through the skin and subcutaneous tissue. With the cautery, the subcutaneous tissue was opened down to the fascia and then again using the Bovie. The fascia was opened in the entire length of the incision on the medial lateral aspect. There was some “bulging” of the muscle and the muscle itself appeared to have a pretty good reddish color. The wounds were irrigated with copious amounts of antibiotic solution and any soft tissue bleeding was hemostatically controlled. It should be noted that the greater saphenous vein was thrombosed. To each of the medial and lateral incisions, a wound VAC dressing was placed that will only have to be changed every other day as compared to a couple of times a day. At the end of the procedure, the right foot and toes were pink once again with fairly good capillary refill. Although she continued to have no palpable dorsalis or posterior tibial pulses, with the use of the Doppler, the dorsalis and posterior tibial signals were easily heard. The patient tolerated the procedure well and was returned to recovery room in satisfactory condition. what are the correct ICD 10 codes Please only code diagnosis codes.

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