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 5, 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 3 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 2 years ago
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 LS to S 1
Preoperative Diagnosis: Radiculopathy and degenerative disc disease at LS-S 1 with recurrent disc herniation at LS-S 1
Postoperative Diagnosis: Same
Procedure Performed: Revision LS laminectomy, revision S 1 laminectomy and diskectomy, stabilization of LS to S 1 with flexible rod Dynesys system
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, complete laminectomy was performed in a subperiosteal fashion with a combination Leksell and Kerrison rongeurs at the LS and S 1 levels. Mobilization of the left S 1 and L5 nerve roots was performed, although there was a significant amount of scar tissue. There was a large free LS-S 1 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 intenupted 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 Sl pedicles bilaterally. These were drilled, probed, dilated, and then a combination of 7.2 mm x 40 mm screws and 7.2 mm x 45 mm screws were placed in the L5 and S 1 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 intenupted 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.
Are these codes correct? 722.10; 338.12, 349.31, 722.52, E870.0, 80.51, 84.82, 03.59
7.33. Discharge Summary
Date of Admission: 2/3
Date of Discharge: 2/4
Discharge Diagnosis: Malignant ascites from metastatic adenocarcinoma of the colon
Course in Hospital: This 59-year-old white female patient was admitted for continuous infusion chemotherapy with 5-FU and Leucovoran. This was done under the care of Dr. ZXY. The patient tolerated her chemotherapy very well. She had no complications throughout her hospital course, and she was discharged to be followed further as an outpatient by her oncologist.
Instructions on Discharge: Follow up in the office
History and Physical
Reason for Admission: Chemotherapy
History of Present Illness: The patient is a 59-year-old white female with peritoneal carcinomatosis and malignant ascites from colon carcinoma. She is admitted for continuous chemotherapy. The patient has a sigmoid colostomy and has had multiple abdominal surgeries for carcinoma; the first one was an anterior and posterior repair in 1982. She had six weeks of radiation therapy completed two years ago and has been on weekly chemotherapy consisting of 5-FU and methotrexate recently. Because of increasing abdominal girth, she was admitted in June and diagnosed with malignant ascites and carcinomatosis. At that time, she had an extensive evaluation including an upper gastrointestinal series, barium enema, CT scan, and ultrasound of the abdomen. She was told she had adhesions causing a partial obstruction. No further surgery was pursued. For the past week, she has complained of frequent vomiting. Her weight has decreased another six pounds. She denies any abdominal pain. She has occasional diarrhea for which she takes Questran. She has had no blood in her colostomy drainage.
Past Medical History: No hypertension, myocardial infarction, diabetes, or peptic ulcer disease. Anterior and posterior repair in 1982, colectomy, cholecystectomy, appendectomy, hysterectomy with bilateral salpingo-oophorectomy for uterine fibroids in 1968.
Chronic Medications: Pancrease three times a day; Questran as needed for diarrhea; Os-Cal 2x a day, 250 mg
Family History: Mother died at age 80. Father died of colon cancer at age 60.
Social History: Prior to that time, she smoked a pack a day for 20 years. She denies any alcohol intake. She works in the shipping department.
Review of Systems: Unremarkable
Physical Examination: An alert, white female in no acute distress
Skin, Head, Eyes, Ears, Nose, Throat: Pupils are equal, reactive to light and accommodation. Extraocular movements are intact. Fundi are benign. Tympanic membranes are normal.
Mouth: No oral lesions are seen.
HEENT: Within normal limits
Neck: Carotids are plus 2 with no bruits. Thyroid is normal. There is no adenopathy at present.
Heart: Regular sinus rhythm. No murmur, rub, or gallop.
Breasts: A small, approximately 3-mm, cystic lesion the medial aspect of her left breast at around eight o’clock. It is freely movable and nontender. There are no axillary nodes.
Abdomen: Distended. Sigmoid colostomy present. Right lower quadrant induration is present. There is no abdominal tenderness. There is no hepatosplenomegaly. Bowel sounds are normal.
Pulses: Femorals are plus 2 with no bruits. There are good pedal pulses bilaterally.
Extremities: No edema
Neurologic: Deep tendon reflexes are plus 2 throughout
Laboratory Data: Pending
Peritoneal carcinomatosis from colon cancer
Small left breast cyst
Plan: The patient will be admitted for continuous chemotherapy.
2/3 Patient tolerating chemo well. No complaints offered.
2/4 Patient well hydrated, nausea and vomiting under control. Will discharge.
Are these codes correct? 197.6, 789.51, 789.51, V10.05, V44.3, V16.0, V15.3, V15.82, 38.93, 99.25
The post 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 5, 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 3 weeks after discharge. He was given Percocet and Flexeril for pain and spasms, as needed. appeared first on commompapers.org.
Hi there! Click one of our representatives below and we will get back to you as soon as possible.