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Get Answer: Procedure Codes Patient Question Guide

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PROCEDURE CODES FOR: PATIENT: CALLMAN, LOUISE ACCOUNT/EHR #: CALLLO001 Preoperative Dx: Stenotic cervical os with hematometrium Postoperative Dx: Same Operation: Cervical dilatation with release of old blood. This was done under ultrasound guidance followed by endometrial curettage. Surgeon: Rodney L. Cohen, MD Anesthesia: General by LMA Complications: None Specimens: Endometrial curettings to pathology Disposition: Stable to recovery room PROCEDURE: The patient was taken to the OR, where she was placed in the supine position and administered general anesthesia per LMA. She was then placed in candy-cane stirrups and prepped and draped in the usual sterile fashion. A weighted speculum was placed in the vagina, and with the aid of a Deaver retractor, the anterior portion of the cervix was grasped with single-toothed tenaculum. There were no evident holes or dimples or scenes suggestive of where the external cervical os might be, as the cervix had completely agglutinated across the entire surface. Using lacrimal ducts and gentle tension, the area of suspicion was gently poked until a perforation gave way. This tract was followed with serial dilators until ultimately brown old blood was released, ensuring that I was in the right place. This was done with the aid of abdominal ultrasound guidance, for the risk of false tracking and missing the endocervical canal uterus was real. The uterus was emptied. The cervix was dilated up to approximate 8 mm. This allowed for free flow of the contained old blood. This was followed by sharp curette of all the uterine lining surfaces. This specimen was captured and sent to pathology. Lastly, a small 7 size suction catheter was inserted to ensure the remainder of any old captured blood that may be sitting in the deep recesses of this severely retroverted uterus was obtained, and this concluded the case. The instruments were removed. The patient was taken down from candy-cane stirrups. The patient was awakened from anesthesia and taken to the recovery room in stable condition. ALREADY HAVE CODES 58120 AND 76998

 
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