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7.32. Discharge Summary Admission Date: November 15, 20XX Discharge...

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7.32. Discharge Summary Admission Date: November 15, 20XX Discharge...

7.32. Discharge Summary

Admission Date: November 15, 20XX

Discharge Date: November 20, 20XX

Description: The patient is a 49-year-old male who was admitted on November 15. He underwent revision laminectomy and stabilization of his lumbar spine with a Dynesys system. The patient tolerated the procedure well and had an uneventful hospital course, except experienced acute pain after the surgery requiring additional physical therapy and pain control.

By postoperative day five, he was tolerating a regular diet, had obtained pain control, and cleared physical therapy. He was subsequently discharged home with written instructions. He is to follow up in three weeks after discharge. He was given Percocet and Flexeril for pain and spasms, as needed.

History and Physical

Admit Diagnosis: Recurrent herniated disc

Procedure: Lumbar laminectomy, disc stabilization with Dynesys

History of Present Illness: 49-year-old male with left leg and back pain. Diagnosed with recurrent disc herniation

Past Medical History: Status post laminectomy and diskectomy two years ago

Physical Examination

Neck: Supple

Heart: Regular rate and rhythm

Lungs: Clear to auscultation

Neuro: Left leg weakness, numbness, and pain

Skin: No lesions, masses, or rashes

Assessment and Plan: Recurrent HNP L5 to S1

Operative Report

Preoperative Diagnosis: Radiculopathy and degenerative disc disease at L5-S1 with recurrent disc herniation at L5-S1

Postoperative Diagnosis: Same

Procedure Performed: Revision L5 laminectomy, revision S1 laminectomy and diskectomy, stabilization of L5 to S1 with flexible rod Dynesys system

Anesthesia: General

Blood Loss: Minimal

Complications: Intraoperative dural tear, which was repaired with watertight seal with interrupted 4-0 Nurolon sutures

Description of the Procedure: Under sterile conditions, the patient was brought to the operating room and was placed under general endotracheal anesthesia and placed in a prone position. Lumbar spine was then prepped and draped in the usual sterile manner with a Betadine prep. A lateral x-ray was obtained with an 18-gauge spinal needle placed for level localization. Based upon the x-ray, a direct posterior approach to the lumbar spine was performed. This was carried down to the transverse process of L5 and the sacral ala bilaterally. After adequate exposure, partial laminectomy was performed in a subperiosteal fashion with a combination Leksell and Kerrison rongeurs at the L5 and S1 levels. Mobilization of the left S1 and L5 nerve roots was performed, although there was a significant amount of scar tissue. There was a large free L5-S1 recurrent disc fragment, which was removed with a pituitary rongeur. There was a small dural tear within the axilla of the L5 nerve root repaired with watertight seal with interrupted 4-0 Nurolon sutures. After adequate decompression, attention was brought to stabilization. Using the usual internal and external landmarks, pedicle screws were placed in the L5 and S1 pedicles bilaterally. These were drilled, probed, dilated, and then a combination of 7.2 mm × 40 mm screws and 7.2 mm × 45 mm screws were placed in the L5 and S1 pedicles bilaterally. AP and lateral x-rays were obtained, noting appropriate placement of the screws. Measuring of the cord device was performed bilaterally. The cord was placed in the usual fashion, tensioned, and then finally tightened. The wound was copiously irrigated with bacitracin solution. No drain was utilized. The fascia was closed with interrupted 0 Vicryl suture. The subcutaneous tissue and skin were closed in three sequential layers. The patient was awakened in the operating room, extubated, and brought to the recovery room in satisfactory condition.

Code Assignment Including POA Indicator

What is the ICD-10-CM Principal Diagnosis?

What is the ICD-10-CM Additional Diagnoses?

What is the ICD-10-PCS Procedure Code(s)?

 

7.34. Discharge Summary

Date of Admission: 1/3

Date of Discharge: 1/7

Discharge Diagnosis: Recurrent carcinoma, left lung

This is a 63-year-old female who is two years status post left upper lobe resection for adenocarcinoma. Pathology at that time revealed a positive bronchial margin of resection. She was treated with postop radiation and has done extremely well. She has remained asymptomatic with no postoperative difficulty. Follow-up serial CT scans have revealed a new lesion in the apical portion of the left lower lobe of the lung, which on needle biopsy was positive for adenocarcinoma. She was admitted specifically for a left thoracotomy and possible pneumonectomy.

Past Medical History: Positive for tobacco abuse. The patient smoked two packs per day for approximately 30 years but quit smoking 15 years ago. Significant for a right parotidectomy and significant for hypertension, degenerative disc disease of lumbar spine, and chronic obstructive pulmonary disease. The patient also suffered a cerebral infarction in the left brain with resulting in right dominant hemiparesis three years ago. Medications on discharge: Tenormin 25 mg once a day, Calan SR 240 mg twice a day, Moduretic one tablet q. day, K-Dur 10 meq q. day, Proventil MDI 2 puffs PO q.i.d. p.r.n., Azacort MDI 2 puffs PO t.i.d., Vioxx 25 mg PO daily.

Physical Examination: Revealed a well-healed right parotid incision. No supraclavicular adenopathy. She has a healed left posterior lateral thoracotomy scar. Impression is that of local recurrence, status post left upper lobectomy. She is to undergo a left pneumonectomy.

Operative Findings and Hospital Course: There was a large mass in the remaining lung, extensive mediastinal fibrosis, bronchial margin free by frozen section. Following surgery she was placed in the intensive care unit postoperatively. The chest tube was removed on postoperative day number two. She experienced some EKG changes consistent with acute nontransmural MI. Cardiology was consulted, and she was started on nitroglycerin and IV heparin. She was eventually weaned from her oxygen therapy.

She was started on regular diet and was discharged in good condition. Her wound was clean and dry.

Instructions on Discharge: Discharged home with instructions to follow up with cardiology next week. Also follow up with me in the office.

History and Physical

Admitted: 1/3

History of Present Illness: Patient is a 63-year-old right-handed female with history of recurrent adenocarcinoma of apical segment of left upper lobe of lung. She has received radiation therapy to her chest. She weighs 123 pounds. She also has chronic obstructive pulmonary disease.

Review of Systems: She can climb two flights of steps with minimal difficulties. She has a significant underbite. She has stiffness in lower spine, worse in the a.m. She has hypertension and took her Tenormin 25 mg, Calan SR 240 mg this a.m.

Past Surgical History: She had a right parotidectomy seven years ago and was told they needed to use a "very small" ETT. Two years ago she underwent a left upper lobe resection at this facility. Previous health records are being requested.

Allergies: She is allergic to sulfa. Postoperatively last time she received Demerol. She also had hallucinations in the ICU for several days. She blames the hallucinations on the Demerol. The only allergy sign was hallucinations.

Physical Examination: Revealed a well-healed right parotid incision. No supraclavicular adenopathy. She has a healed left posterior lateral thoracotomy scar. Impression is that of local recurrence, status post left upper lobectomy. She is to undergo a left completion pneumonectomy, muscle flap coverage of bronchial stump. The patient has hemiparesis in the right extremities which is her dominant side.

Impression: Recurrent carcinoma left lower lobe of lung.

Plan: Pneumonectomy of left lung. The patient is agreeable to general endotracheal anesthesia or the use of epidural narcotic. She is agreeable to postoperative ventilation if necessary.

Progress Notes

1/3 Attending Physician: Admit for recurrent lung carcinoma, s/p radiation therapy. Consent signed for pneumonectomy. Epidural morphine usage postop explained to and discussed with the patient. She is agreeable.

Anesthesia Preop: Patient evaluated and examined. General anesthesia chosen. Patient agrees. Will provide postop epidural morphine for pain management s/p thoracotomy.

Procedure Note:

Preop Dx: Local recurrence of carcinoma of the lung

Postop Dx: Same

Procedure: Pneumonectomy with muscle flap coverage of bronchial stump

Complications: R/O intraop MI

Anesthesia Postop: Patient in stable condition following GEA with possible intraoperative MI due to hypotension. CPK to be evaluated as available. Patient comfortable with epidural morphine. No adverse effects of anesthesia experienced.

1/4 Attending Physician: Path report confirms recurrent adenocarcinoma. Patient stable but with persistent hypotension resolving slowly—will consult cardiology. CPK MB positive. Incision clean and dry. COPD stable, arthritis stable.

Cardiology Consult: The patient has resolving intraoperative myocardial infarction. Will continue to monitor.

1/5 Attending Physician: Looks and feels well, weaning off morphine. Blood pressure stable. Left pleural space expanding and filling space. Chest tube removed, epidural cath removed.

Cardiology Consult: The patient looking and feeling better.

1/6 Attending Physician: Patient stable for discharge in a.m. Cardiology to follow.

Operative Report

Date: 1/3

Operation: Pneumonectomy

Preoperative Diagnosis: Recurrent carcinoma of left lung

Postoperative Diagnosis: Same

Anesthesia: General endotracheal anesthesia

Operative Findings: There was a large mass in the left lower lobe.

The patient was prepped and draped in the usual fashion. Following thoracotomy the left lung was completely removed. A muscle flap coverage was used for the bronchial stump. During the procedure the patient experienced an episode of hypotension, watch for resulting MI. The patient was fluid resuscitated and sent to the recovery room in good condition.

Pathology Report

Date: 1/3

Specimen: Left lung, resected

Clinical Data: This is a 63-year-old female with recurrent disease on CT scan

Diagnosis: Adenocarcinoma of the apical portion of the lung, bronchial margin is free of disease

Radiology Reports

Date: 1/3

Chest X-Ray: Reveals mass in the left lower lobe. There are surgical clips in the thorax from apparent previous surgery. The thoracic organs are midline and the vasculature is normal.

Impression: Carcinoma LLL, no congestive heart failure

Date: 1/4

Chest X-Ray: Reveals absence of left lung. Other architecture is normal other than post-operative changes. The thoracic organs are midline and the vasculature is normal.

Impression: Postop changes consistent with lobectomy, no congestive heart failure.

EKG Report

Date: 1/3

Normal sinus rhythm

Date: 1/4

There are nonspecific ST changes consistent with possible evolving myocardial infarction.

Date: 1/5

Possible acute myocardial infarction, please correlate with other clinical findings.

Code Assignment Including POA Indicator

What is the ICD-10-CM Principal Diagnosis?

What is the ICD-10-CM Additional Diagnoses?

What is the ICD-10-PCS Procedure Code(s)?

 

7.36. The following documentation is from the health record of a 72-year-old male patient.

Discharge Summary

History of Present Illness: The patient is a 72-year-old male with a history of abdominal perineal resection for colon cancer in 1985 and left hemicolectomy in 1995 for splenic flexure recurrence of cancer. Subsequent right nephrectomy, right adrenalectomy, right posterior hepatic wedge resection in February for metastatic colon carcinoma. The patient is admitted with complaints of lower back pain and bilateral thigh pain for two months, increasing in intensity.

Physical Examination: Examination on admission: Temperature 99°F, pulse 72, respirations 24, blood pressure 150/90. The examination was remarkable for left lower quadrant colostomy from previous operation, mildly tender lumbar spine, and the patient was barely able to stand. It was also noted that the patient had decreased sharp/dull discrimination on the neural examination of the lateral thighs.

Laboratory Data: On admission the laboratory values were: Urinalysis: Specific gravity 1.021, pH 5; chem. tests were negative; nitrite negative; blood negative, 12 white cells, moderate bacteria. The clinical chemistry results were: Serum sodium 141, BUN 42, potassium 4.9, chloride 104, CO2 28, glucose 99, creatinine 1.8, SGOT 12, SGPT 16, alkaline phosphatase 68, total protein 6.6, albumin 3.8, total bilirubin 0.7, direct bilirubin 0.0, GGT 87, calcium 10.3, magnesium 2.0, phosphorus 3.2, uric acid 5.7, PT 12.9, PTT 28.4, white blood cell count 8.0, hemoglobin 15.0, hematocrit 43.8, platelets 223,000. The CEA level was noted to be 508 nanograms per mL on admission. Metastatic workup for the colon carcinoma revealed no evidence of metastatic disease to the head or the thoracic and cervical spine.

Radiologic Studies: CT and MRI revealed left celiac ganglion node plexus enlarged, diagnosed as metastasis. Multiple small lung nodules, bilaterally, suspicious for metastasis. Pathological fracture of L2.

Hospital Course: The patient was treated with physical therapy with continued improve-ment in ambulation with walker. The physical therapy consisted of motor treatment of the lower back and legs with use of therapeutic exercises. Clinically, the patient is afebrile without signs and symptoms of infection, no CVA tenderness, and no dysuria. Subsequent urine culture grew out greater than 10 to the 5th Pseudomonas aeruginosa, which was sensitive to ciprofloxacin. The patient was treated for this UTI due to Pseudomonas aeruginosa with ciprofloxacin 500 mg p.o. q. 8 hours and subsequent urine culture showed no growth. The patient will be discharged home today. Condition on discharge was fairly good.

Treatment: The patient will go home on Vicodin p.o. q. 4 to 6 hours for pain, and Capoten. He will resume Capoten b.i.d. dosing per his internist's recommendations for his hypertension, 25 p.o. b.i.d. Prognosis: The long-term prognosis is poor as the patient has extensive metastatic colon CA; short-term prognosis is fairly good with improvement in ambulation. Ambulation is with walker assistance. Follow-up: The patient will return to see me next Wednesday.

Final Diagnoses: Metastatic colon cancer to right lung, left celiac ganglion node plexus and bone

Pathologic fracture of L2 secondary to metastasis

Code Assignment Including POA Indicator

What is the ICD-10-CM Principal Diagnosis?

What is the ICD-10-CM Additional Diagnoses?

What is the ICD-10-PCS Procedure Code(s)?

 

7.46. The following documentation is from the health record of a 19-year-old female patient.

Discharge Diagnosis: 1. Term pregnancy

2. Previous cesarean section

3. Failed attempt at vaginal birth after cesarean delivery

4. Arrest of descent

5. Obstructed labor secondary to occiput posterior position

Procedures Performed: Repeat low transverse cesarean delivery

History of Present Illness: The patient is a 19-year-old, gravida 3, para 1 with an estimated date of delivery in two weeks. She is with a 37-week pregnancy. She has prior beta strep culture, positive. She underwent spontaneous rupture of membranes. Approximately four hours after the rupture of the membranes, the patient came to the hospital. Upon admission, the patient's membranes were ruptured.

Hospital Course: The patient was started on intravenous Clindamycin for positive group B strep. Further, she was started on Pitocin for induction of labor because of the premature rupture of membranes. The Pitocin was administered via a peripheral vein. The patient had a slow labor course, eventually establishing a good labor curve. She dilated completely to a zero station but failed to descend with pushing. The decision was made to perform a low transverse cesarean delivery because of persistent occipitoposterior position resulting in obstruction. She underwent a cesarean delivery without complications. Estimated blood loss was 600 cc. This resulted in delivery of a live male infant weighing 7 pounds 4 ounces having Apgars of 9 at one minute and 9 at five minutes.

Postoperatively, the patient did well. She was ambulating and tolerating her diet. She was afebrile and her incision looked clear so the patient was discharged home on the third postoperative day.

Medications/Aftercare Plan

1. The patient is to limit her activity around the home for a one-week period.

2. She will be followed up in the office in one to two weeks.

3. Birth control method was discussed and the patient is considering Depo-Provera. She will finalize her decision on this and let us know in the office.

The patient's discharge medications consist of

1. Motrin 800 mg one every eight hours p.r.n.

2. Tylenol #3 1-2 every four hours p.r.n.

3. The patient should continue her prenatal vitamins and irons.

4. Colace 100 mg b.i.d.

5. There are no diet restrictions.

Assign the correct codes:

What is the ICD-10-CM Principal Diagnosis?

What is the ICD-10-CM Additional Diagnoses?

What is the ICD-10-PCS Procedure Code(s)?

 

7.48. The following documentation is from the health record of a 32-year-old female patient.

Inpatient admission: The patient, gravida II, para 1, was admitted at approximately 32 weeks gestation with mild contractions. She was contracting every seven to eight minutes. An ultrasound showed twins of approximately four pounds each. The patient was given magnesium sulfate to stop the contractions, but she contracted through the drug. After developing a fever with suspected chorioamnionitis, a low cervical cesarean section was performed. The umbilical cord was wrapped tightly around the neck of twin one.

Discharge diagnoses: Cesarean delivery of liveborn twins prematurely at 32 weeks gestation; chorioamnionitis; umbilical cord compression.

Code Assignment Including POA Indicator

What is the ICD-10-CM Principal Diagnosis?

What is the ICD-10-CM Additional Diagnoses?

What is the ICD-10-PCS Procedure Code(s)?

Answer & Explanation

Solved by verified expert
Answered by rlianne927 on coursehero.com
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