Patient Here Office Question & Answer Guide (With Explanation)

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What This Question Is About

This question relates to patient here office and requires a structured academic response.

How to Approach This Question

Start by identifying the main issue, then apply relevant academic frameworks.

Key Explanation

This topic involves patient here office. A strong answer should include explanation, application, and examples.

Original Question

The patient is here for office hysteroscopy. She has a long history of dysfunctional bleeding. She is known to have multiple fibroids. Recent ultrasound did demonstrate normal appearing ovaries but several large fibroids, the largest of which is 5 cm in diameter. After informed consent and taking the preop medication, the patient was sterilely prepped. We then injected her with a total of 12 cc of 2 percent Lidocaine without Epinephrine. We then performed an office hysteroscopy using a uterine sound. The uterus sounded to 8 cm. We then dilated the cervical OS with Pratt dilators. The hysteroscope was placed with good visualization of all portions of the endometrium. We were able to identify both tubal ostium. There was a very large fibroid posterior that does press in on the endometrium and occupies much of it. This is not a pedunculated endometrium and is intramural. There are other fibroids that also affect the cavity size and shape, but again these are intramural fibroids and not accessible through the hysteroscope. D&C was performed without difficulty and the patient tolerated the procedure well. Instrument, needle, and sponge count were correct. I advised the patient to see how her symptoms proceed in the next few months. Her last FSH level was 30, suggesting a perimenopausal state. She does understand that the fibroids should shrink in size or at least remain the same once she is menopausal. However, if she feels her bleeding problems are persistent, we may have to consider hysterectomy. The patient will follow up in three or four months and will document her bleeding. Which diagnosis and CPT procedure codes does the surgeon assign?

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