Practicode III (201-300)
Terms in this set (100)
MEDICAL RECORD
OPERATION REPORTAGE: 22Sex: FDATE OF OPERATION: 1/1/20XXPREOPERATIVE
DIAGNOSIS: RECURRENT RIGHT BREAST MASS.PROCEDURES: EXCISION RIGHT
BREAST MASS X 2.POSTOPERATIVE DIAGNOSIS: RECURRENT RIGHT BREAST
MASS.SURGEON:ANESTHESIA: LMA AND LOCAL INFILTRATION.PROCEDURE: The
patient is a female who has a recurrent mass that was multilobulated in the entire
right upper outer quadrant and also a separate mass which was further away from
the nipple at a 9 o'clock position. These two were identified. After skin local
infiltration anesthesia was given.A curvilinear incision was made around the nipple.
CaseID: OPD6918 The skin flaps were raised, so that the entire large mass was exposed. This was
Primary Diagnosis: N63.11 about 2 to 3 cm. The mass was identified below some of the glandula and fat tissue.
Secondary Diagnosis: N63.15 It was completely excised using sharp dissection knife and with possible margin
CPT: 19120-RT around. The patient had smaller breast and there was active gland tissue around the
area of the excision. Once the entire mass was excised. The superior margin was
marked with a sharp silk suture and lateral with a long Prolene and the deep margin
with staple.
Once this was done, on further palpation, there was discrete separate mass in
about 1 cm further lateral at the 9 o'clock position. This was exposed and then
using sharp dissection, this was about 1 cm and removed in total and sent for
pathology separately. The bed was irrigated and inspected. Hemostasis was
achieved. The breast tissue was approximated using 3-0 Vicryl. The skin was closed
using 4-0 Monocryl and sterile dressings were applied.The patient tolerated the
procedure well.Electronically signed by 1/1/20XX
, MEDICAL RECORD
OPERATIVE NOTESex: FAGE: 38DOS: 1/1/20XXPHYSICIAN:PREOPERATIVE
DIAGNOSIS: Bilateral breast hypoplasia.POSTOPERATIVE DIAGNOSIS: Bilateral
breast hypoplasiaOPERATIVE PROCEDURE: Bilateral augmentation using Mentor
moderate-plus profile silicone-filled implants, volume 375 mL, serial number on
the patient's left is xxx. Serial number on the patient's right is
xxx.SURGEON:ANESTHESIA: General.COMPLICATIONS: None.INDICATIONS: Ms.
Smith is a female, who is interested in bilateral breast augmentation for treatment
of breast hypoplasia. She understood the risks of breast asymmetry, capsular
contracture, hematoma, seroma, infection, breast pain, nipple anesthesia, and need
for further surgery. Understanding these risks and possible outcomes, she agreed
CaseID: OPD6919
and wished to proceed with surgery.PROCEDURE: The patient was brought to
Primary Diagnosis: Z41.1
the operating room, where she was placed in supine position. She was placed
Secondary Diagnosis: N64.82
under general anesthesia without incident. She had been marked for augmentation
CPT: 19325-50
in the preoperative holding area. Her chest was sterilely prepped and draped in
usual fashion. I first started on the patient's left. A periareolar incision of 4 cm
length was made along the inferior border. The skin flap was elevated inferiorly
towards the inferior mammary crease. The breast parenchyma in the midline was
then incised and carried down to the chest wall. The inferior border of the pectoralis
major muscle was identified and incised along its border. A submuscular pocket was
developed bluntly. Muscle fiber was released medially to reach the sternal border.
The pectoralis major muscle insertion along the sternum was left intact. The inferior
insertion of the pectoralis major muscle was released. After creation of a
submuscular pocket, I irrigated the pocket out well with saline. With adequate
retraction, I then placed a 375-mL mo
MEDICAL RECORD
OPERATIVE NOTEPHYSICIAN:PREOPERATIVE DIAGNOSES:1. History of left breast
cancer, status post-first-stage breast reconstruction with placement of tissue
expander.2. Left breast cellulitis.POSTOPERATIVE DIAGNOSES:1. History of left
breast cancer, status post-first-stage breast reconstruction with placement of tissue
expander.2. Left breast cellulitis, with infected tissue expander.OPERATIVE
PROCEDURE: Removal of left breast tissue expander with light pocket debridement
and irrigation.SURGEON:ANESTHESIA: Monitored anesthesia care and IV
sedation.INDICATIONS: Ms. Smith is a female who underwent immediate first-stage
breast reconstruction with placement of tissue expander and AlloDerm. Shortly after
CaseID: OPD6920 surgery, she developed erythema consistent with cellulitis. She was started on oral
Primary Diagnosis: T85.79XA antibiotics and after not improving, she was treated with six weeks of IV antibiotics.
Secondary Diagnosis: Z85.3, Z92.21 Her erythema had resolved and she had no pain or evidence of significant edema or
CPT: 11971-LT seroma or abscess. The patient then started chemotherapy and has finished the
chemo. Shortly afterwards she developed some recurrent hyperemia. There was a
concern for possible recurrent infection and she was started on oral antibiotics. She
seemed to improve, but continued to have persistent hyperemia concerning for
cellulitis and possibly deeper infection. After discussing the situation with Dr.
Andrews, we decided that the most appropriate action would be to remove the
expander and to obtain cultures to prevent any overwhelming infection. The patient
agreed and wished to proceed with the surgical procedure.DESCRIPTION OF
PROCEDURE: The patient was brought to the operating room, where she was placed
in a supine position. She was placed under IV sedation. The patient's surgical scars
were infiltrated with 1% lidocaine with epinephrine. The patient's lateral chest w
, MEDICAL RECORD
PATIENT: Smith, SandyAGE: 67SEX: MPrivate Payer (Medicare rules for 65 and
older)DATE OF OPERATION: 01/28/20XXPREOPERATIVE DIAGNOSIS:
COMPRESSION FRACTURES OF T11 AND T12.PROCEDURES: T11 AND T12
VERTEBRAL KYPHOPLASTIES.POSTOPERATIVE DIAGNOSIS: BILATERAL WEDGE
COMPRESSION FRACTURES OF T11 AND T12.ESTIMATED BLOOD LOSS: NO MORE
THAN 1 OR 2 CC.COMPLICATIONS: NONE.SURGEON: Neil Kramer, M.D.FIRST
ASSISTANT:ANESTHESIA: Conscious sedation. Intraservice time 45 mins. The patient
was given a total of 200 mg of propofol intravenously for conscious sedation by MD
and supervised an observing nurse anesthetist for the duration of the procedure.
Periodic assessments were made and patient's vitals were monitored throughout.
CaseID: OPD6923 The pulse was 54, saturations 98, blood pressure 118/69.
Primary Diagnosis: S22.080A INDICATIONS: The patient is an elderly man with a history of back pain after having
Secondary Diagnosis: W19.XXXA suffered a fall. He underwent a workup that included x-rays and an MRI of the spine.
CPT: 22513, 22515, 99152, 99153 This workup revealed the presence of acute wedge compression fractures at the
level of T11 and T12 and his pain corresponded to the area of these wedge
compression fractures. He was referred to neurosurgery for further care. In my clinic, I
evaluated the patient's x-rays and made the recommendation to proceed with a
vertebroplasty as a modality due to his pain and to prevent further compression.
The procedure along with its risks, possible benefits and possible complications
were explained to the patient and his family to their understanding and their
questions were answered to their satisfaction. He consented to the operation as
described.PROCEDURE: The patient brought into the operating room and while
on the stretcher general anesthesia was induced and he was endotracheally
intubated. He was subsequently transferred to the Jackson table in the prone
position where the surgical
MEDICAL RECORD
PREOPERATIVE DIAGNOSIS: RIGHT DISTAL RADIUS COMMINUTED
INTRAARTICULAR FRACTURE.PROCEDURES: ORIF RIGHT WRIST.POSTOPERATIVE
DIAGNOSIS: RIGHT DISTAL RADIUS COMMINUTED INTRAARTICULAR
FRACTURE.SURGEON:ANESTHESIA: GENERAL VIA ENDOTRACHEAL
TUBE.ESTIMATED BLOOD LOSS: MINIMAL.TOURNIQUET TIME: 63
MINUTES.ANTIBIOTICS: 1 GM ANCEF PREOP AND 1 GM ANCEF
POSTOP.COMPLICATIONS: NONE.INDICATIONS: The patient is a right-hand
dominant male who sustained a 2-fragment closed right distal radius comminuted
intraarticular fracture due to motorcycle accident. It was displaced and unable
to adequately close reduced. Options, risks and benefits were discussed with the
CaseID: OPD6925 patient. He agreed with open reduction internal fixation.PROCEDURE: The patient
Primary Diagnosis: S52.571A was brought to the operating room and anesthesia was induced via
Secondary Diagnosis: V29.99XA endotracheal tube. The right upper extremity was prepped and draped in sterile
CPT: 25608-RT fashion. It was exsanguinated, and the tourniquet was inflated to 250.A longitudinal
incision was made over the flexor carpi radialis tendon and taken down through
subcutaneous tissue to the tendon. The sheath was opened, and the tendon was
retracted radialward. The bottom of the sheath was opened, and the severed
tendinous space was exposed. The pronator quadratus was reflected ulnarward.
The fracture was subperiosteally dissected, irrigated out and curetted. Anatomic
reduction was performed, held by hand and an Acumed plate was placed along
the volar surface and adjusted and seemed to be in good position. The oblong
hole was drilled in place and final adjustments were made in the plate. The distal
holes were then drilled, measured and a combination of locking and unlocking lag
screws and plates were placed including the styloid screws.C-arm imaging was
used throughout to ensure good position of the fracture fragments and hardware.
The most proxim
, MEDICAL RECORD
OPERATION REPORTPREOPERATIVE DIAGNOSIS: PRIMARY DEGENERATIVE JOINT
DISEASE, LEFT KNEE.PROCEDURES: LEFT TOTAL KNEE
ARTHROPLASTY.POSTOPERATIVE DIAGNOSIS: PRIMARY DEGENERATIVE JOINT
DISEASE, LEFT KNEE.SURGEON:ANESTHESIA: GENERAL.ESTIMATED BLOOD LOSS:
MINIMAL.DRAINS: HEMOVAC, LEFT KNEE.IMPLANTS: ZIMMER NEXGEN KNEE
COMPONENTS AS FOLLOWS, NEXGEN LEGACY POSTERIOR STABILIZED LPS-
FLEX FEMORAL COMPONENT SIZE G, NEXGEN STEMMED TIBIAL COMPONENT
SIZE 6, ALL POLYETHYLENE PATELLA COMPONENT OF SIZE 38 9.5-MM
THICKNESS, LPS-FLEX TIBIAL ARTICULAR SURFACE 10-MM HEIGHT AND TAPER
STEM PLUG FOR THE TIBIAL COMPONENT.COMPLICATIONS:
NONE.POSTOPERATIVE CONDITION: STABLE.INDICATIONS: The patient is a male
CaseID: OPD6926
with past medical history of hypertension, hepatitis-C and history of left ankle/foot
Primary Diagnosis: M17.0
triple arthrodesis ten years ago, has had chronic history of bilateral knee primary
CPT: 27447-LT
DJD for approximately ten years left greater than right. The patient has severe pain.
The patient had no relief with conservative therapy including anti-inflammatory pain
medications, exercises, rehab, knee braces and steroid injections. The patient was
indicated for a total knee arthroplasty. Surgical option was explained to patient
at length. Risks, benefits and alternatives of surgery were discussed with the patient
at length. Risks explained included but were not limited to infection, bleeding,
nerve vessel damage, possible need for transfusion, knee stiffness, risks of deep
venous thrombosis, pulmonary embolism, risks of pneumonia myocardial function,
risk of anesthesia, need for temporary blood thinners, possible need for prolong
rehab after surgery and possible need for revision of surgery in the future.The
patient understood and accepted all the risks. Surgical consent was signed.
Correct surgical site was marked.PROCEDURE: The patient was brought into th
MEDICAL RECORD
SEX: FEMALE Age: 78DATE OF OPERATION: 1/1/20XXPREOPERATIVE DIAGNOSIS: A
GANGRENE OF RIGHT THIRD TOE.PROCEDURES: OPEN AMPUTATION OF
RIGHT THIRD TOE.POSTOPERATIVE DIAGNOSIS: A GANGRENE OF RIGHT THIRD
TOE.SURGEON: Stephanie Andrews MDANESTHESIA: LOCAL WITH ANESTHESIA
STANDBY.ESTIMATE BLOOD LOSS: LESS THAN 5 CC.COMPLICATIONS:
NONE.INDICATIONS: This patient is a Type II diabetic female with chronic lower
extremity arterial insufficiency. She has developed a progressive gangrene of
the right third toe. Open amputation of the gangrenous right third toe has been
recommended and in addition to intravenous antibiotics and further evaluation and
treatment of her lower extremity arterial insufficiency.PROCEDURE: The patient was
CaseID: OPD6927 taken to the operating room and placed in the supine position on the operating
Primary Diagnosis: E11.52 room table. The patient's right foot, ankle and toes were prepped and draped in the
CPT: 28820-T7 usual sterile fashion. A 1% lidocaine mixed with 0.25% Marcaine was used to
perform a digital block of the right third toe.An elliptical incision was then made at
the base of the right third toe circumferentially. This was carried down through the
subcutaneous tissues. The flexor and extensor tendons of the toe were sharply
divided using a #15 scalpel. The proximal phalanx was then transected using a
bone cutting device.
Specimen was removed from the operative field and sent to pathology for
examination. The operative site was inspected for hemostasis and satisfactory
hemostasis was obtained using sparing electrocautery. The wound was then
irrigated with saline solution and reinspected for hemostasis which was found to
be satisfactory. A single subcuticular dermal suture of 5-0 Vicryl was used to
loosely reapproximate the skin edges in the dorsal aspect of the incision site. The
plantar aspect was left open and packed with saline mo
Terms in this set (100)
MEDICAL RECORD
OPERATION REPORTAGE: 22Sex: FDATE OF OPERATION: 1/1/20XXPREOPERATIVE
DIAGNOSIS: RECURRENT RIGHT BREAST MASS.PROCEDURES: EXCISION RIGHT
BREAST MASS X 2.POSTOPERATIVE DIAGNOSIS: RECURRENT RIGHT BREAST
MASS.SURGEON:ANESTHESIA: LMA AND LOCAL INFILTRATION.PROCEDURE: The
patient is a female who has a recurrent mass that was multilobulated in the entire
right upper outer quadrant and also a separate mass which was further away from
the nipple at a 9 o'clock position. These two were identified. After skin local
infiltration anesthesia was given.A curvilinear incision was made around the nipple.
CaseID: OPD6918 The skin flaps were raised, so that the entire large mass was exposed. This was
Primary Diagnosis: N63.11 about 2 to 3 cm. The mass was identified below some of the glandula and fat tissue.
Secondary Diagnosis: N63.15 It was completely excised using sharp dissection knife and with possible margin
CPT: 19120-RT around. The patient had smaller breast and there was active gland tissue around the
area of the excision. Once the entire mass was excised. The superior margin was
marked with a sharp silk suture and lateral with a long Prolene and the deep margin
with staple.
Once this was done, on further palpation, there was discrete separate mass in
about 1 cm further lateral at the 9 o'clock position. This was exposed and then
using sharp dissection, this was about 1 cm and removed in total and sent for
pathology separately. The bed was irrigated and inspected. Hemostasis was
achieved. The breast tissue was approximated using 3-0 Vicryl. The skin was closed
using 4-0 Monocryl and sterile dressings were applied.The patient tolerated the
procedure well.Electronically signed by 1/1/20XX
, MEDICAL RECORD
OPERATIVE NOTESex: FAGE: 38DOS: 1/1/20XXPHYSICIAN:PREOPERATIVE
DIAGNOSIS: Bilateral breast hypoplasia.POSTOPERATIVE DIAGNOSIS: Bilateral
breast hypoplasiaOPERATIVE PROCEDURE: Bilateral augmentation using Mentor
moderate-plus profile silicone-filled implants, volume 375 mL, serial number on
the patient's left is xxx. Serial number on the patient's right is
xxx.SURGEON:ANESTHESIA: General.COMPLICATIONS: None.INDICATIONS: Ms.
Smith is a female, who is interested in bilateral breast augmentation for treatment
of breast hypoplasia. She understood the risks of breast asymmetry, capsular
contracture, hematoma, seroma, infection, breast pain, nipple anesthesia, and need
for further surgery. Understanding these risks and possible outcomes, she agreed
CaseID: OPD6919
and wished to proceed with surgery.PROCEDURE: The patient was brought to
Primary Diagnosis: Z41.1
the operating room, where she was placed in supine position. She was placed
Secondary Diagnosis: N64.82
under general anesthesia without incident. She had been marked for augmentation
CPT: 19325-50
in the preoperative holding area. Her chest was sterilely prepped and draped in
usual fashion. I first started on the patient's left. A periareolar incision of 4 cm
length was made along the inferior border. The skin flap was elevated inferiorly
towards the inferior mammary crease. The breast parenchyma in the midline was
then incised and carried down to the chest wall. The inferior border of the pectoralis
major muscle was identified and incised along its border. A submuscular pocket was
developed bluntly. Muscle fiber was released medially to reach the sternal border.
The pectoralis major muscle insertion along the sternum was left intact. The inferior
insertion of the pectoralis major muscle was released. After creation of a
submuscular pocket, I irrigated the pocket out well with saline. With adequate
retraction, I then placed a 375-mL mo
MEDICAL RECORD
OPERATIVE NOTEPHYSICIAN:PREOPERATIVE DIAGNOSES:1. History of left breast
cancer, status post-first-stage breast reconstruction with placement of tissue
expander.2. Left breast cellulitis.POSTOPERATIVE DIAGNOSES:1. History of left
breast cancer, status post-first-stage breast reconstruction with placement of tissue
expander.2. Left breast cellulitis, with infected tissue expander.OPERATIVE
PROCEDURE: Removal of left breast tissue expander with light pocket debridement
and irrigation.SURGEON:ANESTHESIA: Monitored anesthesia care and IV
sedation.INDICATIONS: Ms. Smith is a female who underwent immediate first-stage
breast reconstruction with placement of tissue expander and AlloDerm. Shortly after
CaseID: OPD6920 surgery, she developed erythema consistent with cellulitis. She was started on oral
Primary Diagnosis: T85.79XA antibiotics and after not improving, she was treated with six weeks of IV antibiotics.
Secondary Diagnosis: Z85.3, Z92.21 Her erythema had resolved and she had no pain or evidence of significant edema or
CPT: 11971-LT seroma or abscess. The patient then started chemotherapy and has finished the
chemo. Shortly afterwards she developed some recurrent hyperemia. There was a
concern for possible recurrent infection and she was started on oral antibiotics. She
seemed to improve, but continued to have persistent hyperemia concerning for
cellulitis and possibly deeper infection. After discussing the situation with Dr.
Andrews, we decided that the most appropriate action would be to remove the
expander and to obtain cultures to prevent any overwhelming infection. The patient
agreed and wished to proceed with the surgical procedure.DESCRIPTION OF
PROCEDURE: The patient was brought to the operating room, where she was placed
in a supine position. She was placed under IV sedation. The patient's surgical scars
were infiltrated with 1% lidocaine with epinephrine. The patient's lateral chest w
, MEDICAL RECORD
PATIENT: Smith, SandyAGE: 67SEX: MPrivate Payer (Medicare rules for 65 and
older)DATE OF OPERATION: 01/28/20XXPREOPERATIVE DIAGNOSIS:
COMPRESSION FRACTURES OF T11 AND T12.PROCEDURES: T11 AND T12
VERTEBRAL KYPHOPLASTIES.POSTOPERATIVE DIAGNOSIS: BILATERAL WEDGE
COMPRESSION FRACTURES OF T11 AND T12.ESTIMATED BLOOD LOSS: NO MORE
THAN 1 OR 2 CC.COMPLICATIONS: NONE.SURGEON: Neil Kramer, M.D.FIRST
ASSISTANT:ANESTHESIA: Conscious sedation. Intraservice time 45 mins. The patient
was given a total of 200 mg of propofol intravenously for conscious sedation by MD
and supervised an observing nurse anesthetist for the duration of the procedure.
Periodic assessments were made and patient's vitals were monitored throughout.
CaseID: OPD6923 The pulse was 54, saturations 98, blood pressure 118/69.
Primary Diagnosis: S22.080A INDICATIONS: The patient is an elderly man with a history of back pain after having
Secondary Diagnosis: W19.XXXA suffered a fall. He underwent a workup that included x-rays and an MRI of the spine.
CPT: 22513, 22515, 99152, 99153 This workup revealed the presence of acute wedge compression fractures at the
level of T11 and T12 and his pain corresponded to the area of these wedge
compression fractures. He was referred to neurosurgery for further care. In my clinic, I
evaluated the patient's x-rays and made the recommendation to proceed with a
vertebroplasty as a modality due to his pain and to prevent further compression.
The procedure along with its risks, possible benefits and possible complications
were explained to the patient and his family to their understanding and their
questions were answered to their satisfaction. He consented to the operation as
described.PROCEDURE: The patient brought into the operating room and while
on the stretcher general anesthesia was induced and he was endotracheally
intubated. He was subsequently transferred to the Jackson table in the prone
position where the surgical
MEDICAL RECORD
PREOPERATIVE DIAGNOSIS: RIGHT DISTAL RADIUS COMMINUTED
INTRAARTICULAR FRACTURE.PROCEDURES: ORIF RIGHT WRIST.POSTOPERATIVE
DIAGNOSIS: RIGHT DISTAL RADIUS COMMINUTED INTRAARTICULAR
FRACTURE.SURGEON:ANESTHESIA: GENERAL VIA ENDOTRACHEAL
TUBE.ESTIMATED BLOOD LOSS: MINIMAL.TOURNIQUET TIME: 63
MINUTES.ANTIBIOTICS: 1 GM ANCEF PREOP AND 1 GM ANCEF
POSTOP.COMPLICATIONS: NONE.INDICATIONS: The patient is a right-hand
dominant male who sustained a 2-fragment closed right distal radius comminuted
intraarticular fracture due to motorcycle accident. It was displaced and unable
to adequately close reduced. Options, risks and benefits were discussed with the
CaseID: OPD6925 patient. He agreed with open reduction internal fixation.PROCEDURE: The patient
Primary Diagnosis: S52.571A was brought to the operating room and anesthesia was induced via
Secondary Diagnosis: V29.99XA endotracheal tube. The right upper extremity was prepped and draped in sterile
CPT: 25608-RT fashion. It was exsanguinated, and the tourniquet was inflated to 250.A longitudinal
incision was made over the flexor carpi radialis tendon and taken down through
subcutaneous tissue to the tendon. The sheath was opened, and the tendon was
retracted radialward. The bottom of the sheath was opened, and the severed
tendinous space was exposed. The pronator quadratus was reflected ulnarward.
The fracture was subperiosteally dissected, irrigated out and curetted. Anatomic
reduction was performed, held by hand and an Acumed plate was placed along
the volar surface and adjusted and seemed to be in good position. The oblong
hole was drilled in place and final adjustments were made in the plate. The distal
holes were then drilled, measured and a combination of locking and unlocking lag
screws and plates were placed including the styloid screws.C-arm imaging was
used throughout to ensure good position of the fracture fragments and hardware.
The most proxim
, MEDICAL RECORD
OPERATION REPORTPREOPERATIVE DIAGNOSIS: PRIMARY DEGENERATIVE JOINT
DISEASE, LEFT KNEE.PROCEDURES: LEFT TOTAL KNEE
ARTHROPLASTY.POSTOPERATIVE DIAGNOSIS: PRIMARY DEGENERATIVE JOINT
DISEASE, LEFT KNEE.SURGEON:ANESTHESIA: GENERAL.ESTIMATED BLOOD LOSS:
MINIMAL.DRAINS: HEMOVAC, LEFT KNEE.IMPLANTS: ZIMMER NEXGEN KNEE
COMPONENTS AS FOLLOWS, NEXGEN LEGACY POSTERIOR STABILIZED LPS-
FLEX FEMORAL COMPONENT SIZE G, NEXGEN STEMMED TIBIAL COMPONENT
SIZE 6, ALL POLYETHYLENE PATELLA COMPONENT OF SIZE 38 9.5-MM
THICKNESS, LPS-FLEX TIBIAL ARTICULAR SURFACE 10-MM HEIGHT AND TAPER
STEM PLUG FOR THE TIBIAL COMPONENT.COMPLICATIONS:
NONE.POSTOPERATIVE CONDITION: STABLE.INDICATIONS: The patient is a male
CaseID: OPD6926
with past medical history of hypertension, hepatitis-C and history of left ankle/foot
Primary Diagnosis: M17.0
triple arthrodesis ten years ago, has had chronic history of bilateral knee primary
CPT: 27447-LT
DJD for approximately ten years left greater than right. The patient has severe pain.
The patient had no relief with conservative therapy including anti-inflammatory pain
medications, exercises, rehab, knee braces and steroid injections. The patient was
indicated for a total knee arthroplasty. Surgical option was explained to patient
at length. Risks, benefits and alternatives of surgery were discussed with the patient
at length. Risks explained included but were not limited to infection, bleeding,
nerve vessel damage, possible need for transfusion, knee stiffness, risks of deep
venous thrombosis, pulmonary embolism, risks of pneumonia myocardial function,
risk of anesthesia, need for temporary blood thinners, possible need for prolong
rehab after surgery and possible need for revision of surgery in the future.The
patient understood and accepted all the risks. Surgical consent was signed.
Correct surgical site was marked.PROCEDURE: The patient was brought into th
MEDICAL RECORD
SEX: FEMALE Age: 78DATE OF OPERATION: 1/1/20XXPREOPERATIVE DIAGNOSIS: A
GANGRENE OF RIGHT THIRD TOE.PROCEDURES: OPEN AMPUTATION OF
RIGHT THIRD TOE.POSTOPERATIVE DIAGNOSIS: A GANGRENE OF RIGHT THIRD
TOE.SURGEON: Stephanie Andrews MDANESTHESIA: LOCAL WITH ANESTHESIA
STANDBY.ESTIMATE BLOOD LOSS: LESS THAN 5 CC.COMPLICATIONS:
NONE.INDICATIONS: This patient is a Type II diabetic female with chronic lower
extremity arterial insufficiency. She has developed a progressive gangrene of
the right third toe. Open amputation of the gangrenous right third toe has been
recommended and in addition to intravenous antibiotics and further evaluation and
treatment of her lower extremity arterial insufficiency.PROCEDURE: The patient was
CaseID: OPD6927 taken to the operating room and placed in the supine position on the operating
Primary Diagnosis: E11.52 room table. The patient's right foot, ankle and toes were prepped and draped in the
CPT: 28820-T7 usual sterile fashion. A 1% lidocaine mixed with 0.25% Marcaine was used to
perform a digital block of the right third toe.An elliptical incision was then made at
the base of the right third toe circumferentially. This was carried down through the
subcutaneous tissues. The flexor and extensor tendons of the toe were sharply
divided using a #15 scalpel. The proximal phalanx was then transected using a
bone cutting device.
Specimen was removed from the operative field and sent to pathology for
examination. The operative site was inspected for hemostasis and satisfactory
hemostasis was obtained using sparing electrocautery. The wound was then
irrigated with saline solution and reinspected for hemostasis which was found to
be satisfactory. A single subcuticular dermal suture of 5-0 Vicryl was used to
loosely reapproximate the skin edges in the dorsal aspect of the incision site. The
plantar aspect was left open and packed with saline mo
