Practicode:VI (501-600) Study Guide
Questions with Guaranteed Pass
Solutions.
CaseID: OPD6930
Primary Diagnosis: S52.252C, S52.352C
CPT: 25575-LT - Answer MEDICAL RECORD
SEX: MALE Age: 27DATE OF OPERATION: 01/1/20XXPREOPERATIVE DIAGNOSIS: LEFT BOTH
BONE FOREARM OPEN FRACTURE DISPLACED COMMINUTED DUE TO GUNSHOT WOUND ULNA
AND RADIUS SHAFTS TYPE IIIPROCEDURES: LEFT FOREARM INTRAMEDULLARY NAILING WITH
ACUMED INTRAMEDULLARY NAILS, REPEAT IRRIGATION OF GUNSHOT WOUNDSPOSTOPERATIVE
DIAGNOSIS: LEFT BOTH BONE FOREARM OPEN FRACTURE DISPLACED COMMINUTED DUE TO
GUNSHOT WOUND ULNA AND RADIUS SHAFTS TYPE IIISURGEON: Stephanie Andrews
MDANESTHESIA: GENERAL, ENDOTRACHEAL TUBE.ESTIMATE BLOOD LOSS: 10 CC.TOURNIQUET
TIME: 60 MINUTES.ANTIBIOTICS: ANCEF 1 GM.COMPLICATIONS: NONE.INDICATIONS: The
patient is a male who sustained gunshot wounds to the abdomen and the left forearm and he
was stabilized by general surgery (ulna and radius shaft fractured) Options, risks and benefits
were discussed with the patient and his father and they agreed with the internal fixation. I
recommend an intramedullary rod due to the comminution and the probability of poor fixation
with plating on the radius.PROCEDURE: The patient was brought to the operating room and
anesthesia was induced via endotracheal tube. The left upper extremity was prepped and
draped in sterile fashion. It was elevated, and the tourniquet was inflated to 250.A longitudinal
incision was made over the tip of the olecranon and taken down to the triceps which was split
longitudinally over the tip of the olecranon. The medullary canal was opened with the awl and a
reamer was placed on the medullary canal across the fracture site. The length was measured
and Acumed ulnar nail was then placed and the proximal interlock was placed from the radial to
medial direction using the guide and stab incision. This obtained good purchase.Attention was
then turned to the radius and under C-arm control an incision was made over the distal radius
over the fou
CaseID: OPD6936
Primary Diagnosis: S83.512A
Secondary Diagnosis: M25.362, M25.462
CPT: 29888-LT - Answer MEDICAL RECORD
AGE: 41SEX: MALEDate of Service: 1/1/20XXService Department: Orthopedic Group
GeneralOPERATIVE NOTENAME OF PROCEDURE: Left knee examination under anesthesia,
arthroscopy, and anterior cruciate ligament reconstruction, of an old disruption of the ACL with
chronic instability.SURGEON:ANESTHESIA: General with blocks.DESCRIPTION OF PROCEDURE:
With the patient in the supine position under endotracheal intubation with general anesthesia,
the left knee was examined. There was a moderate amount of clear yellow effusion. There were
intact collateral ligaments. There were positive Lachman, pivot shift, and drawer signs and an
intact PCL.The knee was prepped and draped free in the usual manner. Portals were established
inferolaterally and inferomedially.The medial component had normal cartilage in both articular
surfaces, and the medial meniscus was intact to visualization and probing.The notch had large
,fragments of the anterior cruciate ligament caught in the notch. There was a midsubstance tear,
with some tissue remaining on the femoral side and tibial side.The lateral compartment had
normal cartilage in both articular surfaces. Lateral meniscus, popliteal tendon intact to
visualization and probing.The patellofemoral joint had normal alignment and normal cartilage
on both surfaces. Suprapatellar pouch and both gutters were clear of any loose bodies.In the
notch, we paid our attention to the stump of the anterior cruciate ligament, which was removed
down to bone to expose the tibial spines. We removed soft tissue from the lateral side of the
notch. We performed notchplasty using a curved gouge and power instruments back to the over
the top position.With the knee at 90 degrees, we used an over-the-top guide and made a
proximal mid and tibial area skin incision. We placed a guidewire across the tibia to enter the j
CaseID: OPD6939
Primary Diagnosis: M77.12
CPT: 24359-LT - Answer MEDICAL RECORD
Age: 58Sex: FDate of Service: 1/1/20XXService Department: Orthopedic Group GeneralProvider:
Dr.OPERATIVE NOTE:PREOPERATIVE DIAGNOSIS: Chronic lateral epicondylitis in the left
elbow.POSTOPERATIVE DIAGNOSIS: Same.NAME OF PROCEDURE: Lateral tennis elbow release,
left elbow.SURGEON:DESCRIPTION OF PROCEDURE: The female patient was taken to the
operating room and after satisfactory regional anesthesia, the left elbow was thoroughly
scrubbed, prepped, and draped in the usual manner. A longitudinal incision was made overlying
the later aspect of the elbow. The incision was deepened through the subcutaneous tissue
through the epicondyle. The epicondyle area was exposed by dissecting through the rather
extensive subcutaneous fatty tissue. The interval between the common extensor and the ECRB
was identified. The common extensor was reflected and the underlying ECRB had an area of
necrosis. This was excised. The remaining tendon was sutured together. The anterior aspect of
the lateral epicondyle was roughened with a rongeur. The wound was then irrigated, and the
subcutaneous tissue was closed with 2-0 Vicryl and skin with wire staples. A sterile dressing was
applied.The patient was taken to the recovery room in satisfactory condition with a splint in
place.Electronically signed by 1/1/20XX
CaseID: OPD6950
Primary Diagnosis: M16.11
CPT: 20610-RT, 77002 - Answer MEDICAL RECORD
Age: 87 Sex: FEMALEDate of Service: 01/01/20XXService Department: Orthopedic Group
General Clinic
DIAGNOSIS: Right hip joint primary osteoarthritis.PROCEDURE: Right hip cortisone
injection.SURGEON: Dr. MDDESCRIPTION OF PROCEDURE: The patient was placed on
fluoroscopy table in a supine position. The right hip was identified under fluoroscopy. The skin
was prepped with Betadine, skin anesthetized with 1% lidocaine. Under fluoroscopy guidance, a
22-gauge needle was guided into the right hip capsule using anterolateral approach.
Confirmation made by injection of a small amount of contrast. Once this was confirmed,
injection of bupivacaine and Kenalog was placed in the hip capsule. The patient tolerated the
procedure well without complications, leaving the department in improved, stable condition.
We will see her back to follow up in the office for recheck and reevaluation. Reinjections as
needed.Electronically signed by: MD 1/1/20XX
,CaseID: OPD6958
Primary Diagnosis: S42.022A
CPT: 23515-LT - Answer MEDICAL RECORD
OPERATIVE REPORTSEX: MALE AGE: 35DATE OF OPERATION: 1/1/20XXPREOPERATIVE
DIAGNOSIS: LEFT MIDSHAFT CLAVICLE FRACTURE DISPLACED.PROCEDURES: LEFT CLAVICLE ORIF
WITH FLUOROSCOPY.POSTOPERATIVE DIAGNOSIS: LEFT MIDSHAFT CLAVICLE FRACTURE
DISPLACED.FLUOROSCOPY (Included in Procedure)SURGEON: Dr. MDANESTHESIA: GENERAL,
ENDOTRACHEAL TUBE.ESTIMATE BLOOD LOSS: 100 CC.ANTIBIOTICS: CLINDAMYCIN 900
MG.COMPLICATIONS: NONE.INDICATIONS: The patient is a male who had a motorcycle accident
with the left clavicle fractured which was widely displaced with the proximal fragment
appearing to be impaled into the trapezius. Options, risks and benefits were discussed with the
patient. He agreed with the open reduction internal fixation.PROCEDURE: The patient was
brought to the operating room and anesthesia was induced via endotracheal tube. The left
upper extremity and chest were then prepped and draped in sterile fashion. An incision was
marked over the fractured clavicle and infiltrated with lidocaine 1% with epinephrine. It was
then established, taken down through the subcutaneous tissue to the pectoral trapezial fascia
which was incised longitudinally along the clavicle and the inferior surface of the clavicle was
dissected to protect the lung.The fracture fragments were subperiosteally dissected, irrigated
out and curetted. Anatomic reduction was then performed and held with K-wire. An Acumed
clavicle plate was then placed along the superior surface of the clavicle. A 2.8 drill was used to
create drill holes and the fracture was compressed followed by locking screws. C-arm images
confirmed anatomic reduction and good position of the hardware. The shoulder was put
through a full range of motion.The wound was then irrigated out. Trapezial pectoral fascia was
closed with running and interrupted 2-0 Vicryl. The subcutaneous tissu
CaseID: OPD6971
Primary Diagnosis: I74.2
CPT: 34101-RT - Answer MEDICAL RECORD
OPERATIVE REPORTAGE: 44 Y SEX: FEMALEDATE OF OPERATION: 01/01/20XXPREOPERATIVE
DIAGNOSIS: RIGHT UPPER EXTREMITYPROCEDURES: RIGHT UPPER EXTREMITY BRACHIAL AND
AXILLARY THROMBECTOMY.
POSTOPERATIVE DIAGNOSIS: RIGHT UPPER EXTREMITY THROMBOSIS
SURGEON: M.D.
ANESTHESIA: GENERAL.
ESTIMATED BLOOD LOSS: MINIMAL
COMPLICATIONS: NONE.
INDICATIONS: A female patient was admitted to the hospital with clinical presentation of acute
right upper extremity ischemia. Angiography was done which demonstrated presence of clots in
the right axillary artery. At this point, after consultation with the patient and patient's family, a
decision was made to proceed with a surgical thrombectomy from the right axillary brachial
arteries.
, PROCEDURE: The patient was brought to the operating room and placed on the OR table in the
supine position. General anesthesia was administered. The patient's right upper extremity were
prepped and draped for sterile procedure.Incision was done in the proximal right forearm in
longitudinal direction above the projection of the brachial artery. The brachial artery was
quickly identified and appeared significantly inflamed with the vein tightly adherent to that. A
very difficult dissection was followed in this area and finally brachial artery was dissected taking
on the Vessel loop as well as radial, ulnar and interosseous arteries.The patient was systemically
heparinized with 5000 units of heparin. After 5 minutes of circulation, transverse arteriotomy
was made above the trifurcation of the brachial artery within 2 cm above the bifurcation of the
brachial artery.We could not find the lumen of the artery, which appeared completely occluded.
Finally, we removed something which appeared to be well-organized clot, however, attempt to
send the embolectomy cath in proximal and distal direction were unsuccessf
CaseID: OPD6982
Primary Diagnosis: A63.0
Secondary Diagnosis: Z21
CPT: 46612, 99152 - Answer MEDICAL RECORD
AGE: 53SEX: MALEDATE OF OPERATION:1/1/20XXPREOPERATIVE DIAGNOSIS: ANAL
CONDYLOMATASPROCEDURES: FULGURATION OF ANAL CONDYLOMATAS -
ANOSCOPYPOSTOPERATIVE DIAGNOSIS: ANAL CONDYLOMATASSURGEON: MDConscious
Sedation: Intraservice Time 20 min.ESTIMATED BLOOD LOSS: MINIMAL.INDICATION: The patient
is a 53-year-old male positive for HIV. The patient came into OR for anal
condylomas.PROCEDURE: The patient was brought into the OR at 9 o'clock. The patient was put
in prone position and procedure was done under local anesthesia and conscious sedation. The
patient was put in prone position. The anal area was painted with Betadine and standard drapes
were placed around the area. After giving 16 ccs of lidocaine IV, the anoscope was inserted in
the anus and the electrocauterization was used to remove the condylomas. The whole process
took about 20 minutes. All condylomatas were removed and the wound sites were cleaned. No
active bleeding and Vaseline gauze was used to cover the wound site.The patient was sent to
the PACU after the procedure. The patient was visited by the resident. The patient can be
discharged home. Tylenol #3 and sitz bath instructions have been given to the patient and the
patient can be follow up in the rectal clinic.Electronically signed by: MD 1/1/20XX
CaseID: OPD6986
Primary Diagnosis: K62.3
CPT: 45900 - Answer MEDICAL RECORD
Age: 68Sex: MaleDATE OF OPERATION: 1/1/20XXPREOPERATIVE DIAGNOSIS: PROLAPSE
RECTUM.PROCEDURES: REDUCTION OF PROLAPSED RECTUM UNDER
ANESTHESIA.POSTOPERATIVE DIAGNOSIS: PROLAPSE RECTUM.SURGEON: M.D.ANESTHESIA:
GENERAL VIA FACE MASK.ANESTHESIOLOGIST: RUNG-TAN AndrewsESTIMATE BLOOD LOSS:
NIL.DRAINS: NONE.IV FLUIDS: LACTATED RINGER'SCOMPLICATIONS: NONE.INDICATIONS: This is
a male with history of constipation who presented to the ED with prolapse rectum that was not
reducible by self.PROCEDURE: The patient was brought into the operating room and laid supine
on the operating table. After anesthesia was induced, the patient was placed in the lithotomy
position. A rectal exam was carried out digitally, and the anal sphincter was noted to be lax. The
prolapsed rectum was noted to be viable with no ulceration or ischemia, it was easily reduced
Questions with Guaranteed Pass
Solutions.
CaseID: OPD6930
Primary Diagnosis: S52.252C, S52.352C
CPT: 25575-LT - Answer MEDICAL RECORD
SEX: MALE Age: 27DATE OF OPERATION: 01/1/20XXPREOPERATIVE DIAGNOSIS: LEFT BOTH
BONE FOREARM OPEN FRACTURE DISPLACED COMMINUTED DUE TO GUNSHOT WOUND ULNA
AND RADIUS SHAFTS TYPE IIIPROCEDURES: LEFT FOREARM INTRAMEDULLARY NAILING WITH
ACUMED INTRAMEDULLARY NAILS, REPEAT IRRIGATION OF GUNSHOT WOUNDSPOSTOPERATIVE
DIAGNOSIS: LEFT BOTH BONE FOREARM OPEN FRACTURE DISPLACED COMMINUTED DUE TO
GUNSHOT WOUND ULNA AND RADIUS SHAFTS TYPE IIISURGEON: Stephanie Andrews
MDANESTHESIA: GENERAL, ENDOTRACHEAL TUBE.ESTIMATE BLOOD LOSS: 10 CC.TOURNIQUET
TIME: 60 MINUTES.ANTIBIOTICS: ANCEF 1 GM.COMPLICATIONS: NONE.INDICATIONS: The
patient is a male who sustained gunshot wounds to the abdomen and the left forearm and he
was stabilized by general surgery (ulna and radius shaft fractured) Options, risks and benefits
were discussed with the patient and his father and they agreed with the internal fixation. I
recommend an intramedullary rod due to the comminution and the probability of poor fixation
with plating on the radius.PROCEDURE: The patient was brought to the operating room and
anesthesia was induced via endotracheal tube. The left upper extremity was prepped and
draped in sterile fashion. It was elevated, and the tourniquet was inflated to 250.A longitudinal
incision was made over the tip of the olecranon and taken down to the triceps which was split
longitudinally over the tip of the olecranon. The medullary canal was opened with the awl and a
reamer was placed on the medullary canal across the fracture site. The length was measured
and Acumed ulnar nail was then placed and the proximal interlock was placed from the radial to
medial direction using the guide and stab incision. This obtained good purchase.Attention was
then turned to the radius and under C-arm control an incision was made over the distal radius
over the fou
CaseID: OPD6936
Primary Diagnosis: S83.512A
Secondary Diagnosis: M25.362, M25.462
CPT: 29888-LT - Answer MEDICAL RECORD
AGE: 41SEX: MALEDate of Service: 1/1/20XXService Department: Orthopedic Group
GeneralOPERATIVE NOTENAME OF PROCEDURE: Left knee examination under anesthesia,
arthroscopy, and anterior cruciate ligament reconstruction, of an old disruption of the ACL with
chronic instability.SURGEON:ANESTHESIA: General with blocks.DESCRIPTION OF PROCEDURE:
With the patient in the supine position under endotracheal intubation with general anesthesia,
the left knee was examined. There was a moderate amount of clear yellow effusion. There were
intact collateral ligaments. There were positive Lachman, pivot shift, and drawer signs and an
intact PCL.The knee was prepped and draped free in the usual manner. Portals were established
inferolaterally and inferomedially.The medial component had normal cartilage in both articular
surfaces, and the medial meniscus was intact to visualization and probing.The notch had large
,fragments of the anterior cruciate ligament caught in the notch. There was a midsubstance tear,
with some tissue remaining on the femoral side and tibial side.The lateral compartment had
normal cartilage in both articular surfaces. Lateral meniscus, popliteal tendon intact to
visualization and probing.The patellofemoral joint had normal alignment and normal cartilage
on both surfaces. Suprapatellar pouch and both gutters were clear of any loose bodies.In the
notch, we paid our attention to the stump of the anterior cruciate ligament, which was removed
down to bone to expose the tibial spines. We removed soft tissue from the lateral side of the
notch. We performed notchplasty using a curved gouge and power instruments back to the over
the top position.With the knee at 90 degrees, we used an over-the-top guide and made a
proximal mid and tibial area skin incision. We placed a guidewire across the tibia to enter the j
CaseID: OPD6939
Primary Diagnosis: M77.12
CPT: 24359-LT - Answer MEDICAL RECORD
Age: 58Sex: FDate of Service: 1/1/20XXService Department: Orthopedic Group GeneralProvider:
Dr.OPERATIVE NOTE:PREOPERATIVE DIAGNOSIS: Chronic lateral epicondylitis in the left
elbow.POSTOPERATIVE DIAGNOSIS: Same.NAME OF PROCEDURE: Lateral tennis elbow release,
left elbow.SURGEON:DESCRIPTION OF PROCEDURE: The female patient was taken to the
operating room and after satisfactory regional anesthesia, the left elbow was thoroughly
scrubbed, prepped, and draped in the usual manner. A longitudinal incision was made overlying
the later aspect of the elbow. The incision was deepened through the subcutaneous tissue
through the epicondyle. The epicondyle area was exposed by dissecting through the rather
extensive subcutaneous fatty tissue. The interval between the common extensor and the ECRB
was identified. The common extensor was reflected and the underlying ECRB had an area of
necrosis. This was excised. The remaining tendon was sutured together. The anterior aspect of
the lateral epicondyle was roughened with a rongeur. The wound was then irrigated, and the
subcutaneous tissue was closed with 2-0 Vicryl and skin with wire staples. A sterile dressing was
applied.The patient was taken to the recovery room in satisfactory condition with a splint in
place.Electronically signed by 1/1/20XX
CaseID: OPD6950
Primary Diagnosis: M16.11
CPT: 20610-RT, 77002 - Answer MEDICAL RECORD
Age: 87 Sex: FEMALEDate of Service: 01/01/20XXService Department: Orthopedic Group
General Clinic
DIAGNOSIS: Right hip joint primary osteoarthritis.PROCEDURE: Right hip cortisone
injection.SURGEON: Dr. MDDESCRIPTION OF PROCEDURE: The patient was placed on
fluoroscopy table in a supine position. The right hip was identified under fluoroscopy. The skin
was prepped with Betadine, skin anesthetized with 1% lidocaine. Under fluoroscopy guidance, a
22-gauge needle was guided into the right hip capsule using anterolateral approach.
Confirmation made by injection of a small amount of contrast. Once this was confirmed,
injection of bupivacaine and Kenalog was placed in the hip capsule. The patient tolerated the
procedure well without complications, leaving the department in improved, stable condition.
We will see her back to follow up in the office for recheck and reevaluation. Reinjections as
needed.Electronically signed by: MD 1/1/20XX
,CaseID: OPD6958
Primary Diagnosis: S42.022A
CPT: 23515-LT - Answer MEDICAL RECORD
OPERATIVE REPORTSEX: MALE AGE: 35DATE OF OPERATION: 1/1/20XXPREOPERATIVE
DIAGNOSIS: LEFT MIDSHAFT CLAVICLE FRACTURE DISPLACED.PROCEDURES: LEFT CLAVICLE ORIF
WITH FLUOROSCOPY.POSTOPERATIVE DIAGNOSIS: LEFT MIDSHAFT CLAVICLE FRACTURE
DISPLACED.FLUOROSCOPY (Included in Procedure)SURGEON: Dr. MDANESTHESIA: GENERAL,
ENDOTRACHEAL TUBE.ESTIMATE BLOOD LOSS: 100 CC.ANTIBIOTICS: CLINDAMYCIN 900
MG.COMPLICATIONS: NONE.INDICATIONS: The patient is a male who had a motorcycle accident
with the left clavicle fractured which was widely displaced with the proximal fragment
appearing to be impaled into the trapezius. Options, risks and benefits were discussed with the
patient. He agreed with the open reduction internal fixation.PROCEDURE: The patient was
brought to the operating room and anesthesia was induced via endotracheal tube. The left
upper extremity and chest were then prepped and draped in sterile fashion. An incision was
marked over the fractured clavicle and infiltrated with lidocaine 1% with epinephrine. It was
then established, taken down through the subcutaneous tissue to the pectoral trapezial fascia
which was incised longitudinally along the clavicle and the inferior surface of the clavicle was
dissected to protect the lung.The fracture fragments were subperiosteally dissected, irrigated
out and curetted. Anatomic reduction was then performed and held with K-wire. An Acumed
clavicle plate was then placed along the superior surface of the clavicle. A 2.8 drill was used to
create drill holes and the fracture was compressed followed by locking screws. C-arm images
confirmed anatomic reduction and good position of the hardware. The shoulder was put
through a full range of motion.The wound was then irrigated out. Trapezial pectoral fascia was
closed with running and interrupted 2-0 Vicryl. The subcutaneous tissu
CaseID: OPD6971
Primary Diagnosis: I74.2
CPT: 34101-RT - Answer MEDICAL RECORD
OPERATIVE REPORTAGE: 44 Y SEX: FEMALEDATE OF OPERATION: 01/01/20XXPREOPERATIVE
DIAGNOSIS: RIGHT UPPER EXTREMITYPROCEDURES: RIGHT UPPER EXTREMITY BRACHIAL AND
AXILLARY THROMBECTOMY.
POSTOPERATIVE DIAGNOSIS: RIGHT UPPER EXTREMITY THROMBOSIS
SURGEON: M.D.
ANESTHESIA: GENERAL.
ESTIMATED BLOOD LOSS: MINIMAL
COMPLICATIONS: NONE.
INDICATIONS: A female patient was admitted to the hospital with clinical presentation of acute
right upper extremity ischemia. Angiography was done which demonstrated presence of clots in
the right axillary artery. At this point, after consultation with the patient and patient's family, a
decision was made to proceed with a surgical thrombectomy from the right axillary brachial
arteries.
, PROCEDURE: The patient was brought to the operating room and placed on the OR table in the
supine position. General anesthesia was administered. The patient's right upper extremity were
prepped and draped for sterile procedure.Incision was done in the proximal right forearm in
longitudinal direction above the projection of the brachial artery. The brachial artery was
quickly identified and appeared significantly inflamed with the vein tightly adherent to that. A
very difficult dissection was followed in this area and finally brachial artery was dissected taking
on the Vessel loop as well as radial, ulnar and interosseous arteries.The patient was systemically
heparinized with 5000 units of heparin. After 5 minutes of circulation, transverse arteriotomy
was made above the trifurcation of the brachial artery within 2 cm above the bifurcation of the
brachial artery.We could not find the lumen of the artery, which appeared completely occluded.
Finally, we removed something which appeared to be well-organized clot, however, attempt to
send the embolectomy cath in proximal and distal direction were unsuccessf
CaseID: OPD6982
Primary Diagnosis: A63.0
Secondary Diagnosis: Z21
CPT: 46612, 99152 - Answer MEDICAL RECORD
AGE: 53SEX: MALEDATE OF OPERATION:1/1/20XXPREOPERATIVE DIAGNOSIS: ANAL
CONDYLOMATASPROCEDURES: FULGURATION OF ANAL CONDYLOMATAS -
ANOSCOPYPOSTOPERATIVE DIAGNOSIS: ANAL CONDYLOMATASSURGEON: MDConscious
Sedation: Intraservice Time 20 min.ESTIMATED BLOOD LOSS: MINIMAL.INDICATION: The patient
is a 53-year-old male positive for HIV. The patient came into OR for anal
condylomas.PROCEDURE: The patient was brought into the OR at 9 o'clock. The patient was put
in prone position and procedure was done under local anesthesia and conscious sedation. The
patient was put in prone position. The anal area was painted with Betadine and standard drapes
were placed around the area. After giving 16 ccs of lidocaine IV, the anoscope was inserted in
the anus and the electrocauterization was used to remove the condylomas. The whole process
took about 20 minutes. All condylomatas were removed and the wound sites were cleaned. No
active bleeding and Vaseline gauze was used to cover the wound site.The patient was sent to
the PACU after the procedure. The patient was visited by the resident. The patient can be
discharged home. Tylenol #3 and sitz bath instructions have been given to the patient and the
patient can be follow up in the rectal clinic.Electronically signed by: MD 1/1/20XX
CaseID: OPD6986
Primary Diagnosis: K62.3
CPT: 45900 - Answer MEDICAL RECORD
Age: 68Sex: MaleDATE OF OPERATION: 1/1/20XXPREOPERATIVE DIAGNOSIS: PROLAPSE
RECTUM.PROCEDURES: REDUCTION OF PROLAPSED RECTUM UNDER
ANESTHESIA.POSTOPERATIVE DIAGNOSIS: PROLAPSE RECTUM.SURGEON: M.D.ANESTHESIA:
GENERAL VIA FACE MASK.ANESTHESIOLOGIST: RUNG-TAN AndrewsESTIMATE BLOOD LOSS:
NIL.DRAINS: NONE.IV FLUIDS: LACTATED RINGER'SCOMPLICATIONS: NONE.INDICATIONS: This is
a male with history of constipation who presented to the ED with prolapse rectum that was not
reducible by self.PROCEDURE: The patient was brought into the operating room and laid supine
on the operating table. After anesthesia was induced, the patient was placed in the lithotomy
position. A rectal exam was carried out digitally, and the anal sphincter was noted to be lax. The
prolapsed rectum was noted to be viable with no ulceration or ischemia, it was easily reduced
