Get Answer: Case Preoperative Postoperative Question Guide
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Original Question
Case 2 Preoperative and postoperative diagnosis: Left hydrocele Procedure: hydrocelectomy This 39-year-old male was brought to the operating room and prepared an raped in the usual fashion. General anesthesia was administered, and the patient was placed in the lithotomy position. On the left scrotum, a 3.4-cm incision was made. A hydrocele was visualized, and by dissection, it was freed and removed through the incision site. After removing the hydrocele, sutures were used to close the site. A drain ws placed and the wound was closed in layers. The patient was returned to the recovery suite in satisfactory condition. Blood loss was minimal. CPT codes: Case 3 Preoperative diagnosis: Prostate tumor Postoperative diagnosis: Same Anesthesia: conscious sedation Procedure performed: Needle biopsy of the prostate Procedure: Moderate sedation was administered, and all precautions were taken and documented on the surgical flow sheet. Verification of the questionable site using transabdominal and prostate ultrasound was performed. The biopsy needle was guided to the area of the prostate in question, and the sheath was advanced over the needle and twisted to obtain the sample. This procedure was repeated two more times to be sure that we had adequate sampling. All samples were sent pathology for testing. CPT code(s) Case 2 Preoperative diagnosis: Pelvic pain preventing pelvic exam Postoperative diagnosis: Vulvar adhesions The patient was placed under general anesthesia and placed in the supine lithotomy position. Examination of the pelvis revealed multiple adhesions in the vulvar area. The vagina and cervix were examined and found to be normal. The patient tolerated the procedure and was sent to recovery. Additional therapeutic procedures will be discussed with the patient. CPT code(s) Case 3 Preoperative diagnosis: Vaginal stricture Postoperative diagnosis: vaginal stricture Procedure: Repair of introitus The patient was brought to the operating room and prepped and draped in the usual fashion. Geneal anesthesia was given, and the surgical site was cleansed. Three V-shaped incisions were made in the area of the vaginal stricture. Because of the amount of scar tissue present, the tissue was excised. To obtain hemostasis, the mucosa was sewn with sutures, thus repairing the area. The patient tolerated the procedure with minimal blood loss. CPT code(s):
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