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Original Question

CASE 1 (Process 3: Modifiers) Preoperative diagnosis: Chronic tonsillitis and enlarged adenoids Postoperative diagnosis: Chronic tonsillitis and enlarged adenoids Procedure: Tonsillectomy with adenoidectomy The patient, a 6-year-old male, was placed under general anesthesia for bilateral removal of tonsils with adenoids. The tonsils were grasped with an Allis forceps, and the incision made around the anterior tonsillar pillar. The tonsillar capsule was identified, and the tonsils bluntly dissected free. Next we turned our attention to the nasopharynx, which was viewed indirectly. There was a considerable amount of hypertrophic adenoids present; they were removed by curette, and all nubbins of adenoid tissue were removed. All bleeding was controlled with pressure sponges, and several small bleeding areas were touched with electrocoagulation. At the close of both procedures, there was no bleeding present. Blood loss was minimal, and the postoperative condition of the patient was good. Were additional procedures performed during the operative session, and does the documentation support them?

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