Preoperative Diagnosis Subdural Explained for Students (Easy Guide)

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Original Question

PREOPERATIVE DIAGNOSIS Subdural hematoma. POSTOPERATIVE DIAGNOSIS Subdural hematoma. PRIMARY PROCEDURE BURR HOLE FOR EVACUATION AND DRAINAGE OF SUBDURAL HEMATOMA. BRIEF HISTORY The patient is a 16-year-old student. At her high school, she was standing on the top of a “human pyramid,” lost her balance and fell on her head hitting the right side. She immediately felt drowsy and confused. By the time the paramedics arrived, she complained of a unilateral headache on the right side. Pupillary dilation was ipsilateral to the injured side. At the hospital, the location of the hematoma was located by angiography followed by x-ray and a CT scan. 31 0201664AS05A-13 Medical Coding PROCEDURE The consent form was signed by the parents, and the patient was taken to the operating room. She was anesthetized, and the right frontotemporal region was prepped and draped. A burr hole, using a rounded tip, was made into the skull. Immediate evacuation and decompression resulted. The patient’s vitals were stable, and she was discharged to the neurosurgeon for evaluation of a craniotomy. Note: External cause code(s) apply. ICD-10-CM: _____ ICD-10-CM: _____ ICD-10-CM: _____ ICD-10-CM: _____ 28. CPT: ____ ANSWERS NEED TO BE IN ACCORDANCE WITH ICD-10-CM 2024 AND CPT 2023

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