Preoperative Diagnosis Menometrorrhagia Explained for Students (Easy Guide)

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Preoperative Diagnosis: Menometrorrhagia and endometrial polyp. Postoperative Diagnosis: Same. Operation: Diagnostic hysteroscopy with Endometrial ablation and Fractional dilation and curettage. Operative Findings: The uterus sounded to a depth of 8.5 cm. The cervical length was 4 cm and the cavity depth was 4.5 cm. Cavity width was 4 cm and treatment cycle was 80 seconds. The power setting was 99. Description of Procedure: The 42-year-old female patient was brought to the operating room suite and general anesthesia was administered. The patient is placed in the dorsal-lithotomy position and her vagina and perineum were sterilely prepped and draped in the usual fashion. The bladder was decompressed with an in-and-out catheter. The weighted speculum was placed into the vagina after bimanual pelvic examination had been performed revealing a midline positioned uterus. The anterior lip of the cervix was grasped with a single-tooth tenaculum. The uterus was sounded to a depth of 8.5 cm; however, the internal cervical os could not be palpated with the uterine sound. Sure sound was therefore used to find a cervical length of 4 cm and a cavity length of 4.5 cm. This being accomplished, the diagnostic hysteroscopy was performed. Both tubal ostia were visualized. There was no evidence of intracavitary defect. Endometrial tissue was visible including polyps. Glycine was used as the distending media. The hysteroscope was withdrawn. The cervix was dilated to allow the admission of a #4 sharp curette. Uterine curettage was performed until a good uterine cry was noted. The polyp forceps was used to extract remaining fragments of tissue. The tissue was sent to Pathology for evaluation. Now the NovaSure instrument was placed and the settings accomplished giving a power setting of 99. After cavity assessment was passed, the ablation procedure was initiated. The ablation procedure treatment cycle lasted 80 seconds. The array was closed, the instrument withdrawn, and then general anesthesia was reversed. The patient was taken to the recovery room in stable and satisfactory condition having tolerated the procedure well. All sponge, instrument, and needle counts were correct. The estimated blood loss was 3 cc. Specimens: Endometrial curettings Assign the correct diagnosis and procedure codes: ICD-10-CM code 1: ICD-10-CM code 2: CPT code:

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