Cpt code for antrectomy

CHAPIER 23 r DiSestive System

PRACTICAT

Using the CPT and ICD-10-CM/ICD-9-CM manuals, code the following:

19. Rigid esophagoscopy with removal of a foreigntody.

CPT Code:

Ligation of an intraoral salivary duct.

CPT Code:

21,. Transection of esophagus with repair of esophageal varices.

CPT Code:

,/22. Enterotomy of the small intestine for removal of a foreign body.

CPT Code:

23. Complicated revision of a colostomy.

CPT Code:

,t. Pr"notomy, labial.

CPT Code:

25. Excision of a

CPT Code:

palate lesion without closure.

29.

n{u. *"^oval of a foreign body from the pharynx.

CPT Code:

27. Amy is an l8-year-old with severe snoring. She is having an adenoidectomy in order to treat her snoring.

,/CW Code: ./

/Zg. partial colectomy with cotostomy.

CPT Code:

Open repair of an incarcerated recurrent inguinal hernia.

CPT Code:

0. Surgical laparoscopic placement of a gastric band.

CPT Code:

Odd-numbered answers are located ln Appendix B, while the full answer key is only avallable in the TEACE rnstfuctor Resources on Evolve.

Copyright @ 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved.

CHAPTER !l r Digestive System

31. Fuli-thickness repair of the vermilion of the lip'

i CPT Code: \'4, ,,,,,0,.,.,

CPT Code:

33. Bilateral Pa

CPT Code:

epair of 1.6-cm laceration of floor of mouth'

rotid duct diversion.

,i. s,ugicar laparoscopic repair of a paraesophageal hernia with fundoplasty

with imPlantation of mesh'

CPT Code:

Biopsy of the stomach by laparotomy'

*d6. Nontune open ileostomY'

CPT Code:

37. Coiorrhaphy for multiple perforations of large

-' auto accihent. No colostomy was required'

rzls. tncision and drainage of perirectal abscess'

CPT Code:

39. Diagnostic abdominal laParoscoPY'

fo. r*urRocEDURE DIAGNoSIS: Screening coionoscopy'

POSTPROCEDURE DIAGNOSIS: Colon polyps'

PREMEDICATIONS: Fentanyl 100 mcg and Versed 4 mg'

PROCEDURE: A colonoscopy was perform:q to th.:,:"cum' The scope

was advanced to the cecum urd.r'dir..t vision without any difflculty'

FINDINGS:Thececum,ascending'transverse',desc11ding'andsigmoid colon *r, t'o'-ui' r" trt" d""""8i"g colott' there was a Z-mm

polyp

that was biopsied and submitted for histoiogy'

ASSESSMENT Diminutive colon polyps'

odd-numbered answers are located rn Appendrx B, while the futl a'swer key is only avallable in

the TEACTT

Instructor Resources on Evolve'

35.

intestine sustained in

Copyright @ 2015 by Saunders, an impdnt of Elsevier Inc' A11 rights reserved

CHAPTER 23 r Digestive System

REPORTS

In Appendix A of this workbook you will find a section titled Reports, which ,onfiins original reports. Read the reports indicated below and supply the appropriate cPT and ICD-L0-CMfiCD-9-CM codes on the following lines:

v42. Report 22

& rcp-ro-cM code(s):

.1& tco-l-cM code(s):

d+. xeport zz

& cvr code(s):

& Ico-ro-cM code(s):

(& tcp-g-cM code(s):

43. Report 31

& cpr code(s):

& cpr code(s):

& lco-ro-cM code(s):

(& ICD-g-cM code(s):

45. Report 33

& cpr code(s):

& rco-ro-cM code(s):

(& ICD-g-cM code(s):

&

&

(e

d. v"port z+ CPT Code(s):

ICD-1O-CM Code(s):

ICD-9-CM Code(s):

& Ur"r to declde number of codes necessary to correctly answer the question. Odd-numbered answers are located ln Appendix B, while the full arlswer key is only available in the TEACfl Instructor Resources on Evolve.

Coppight O 2015 by Saunders, an imprint of Elsevier Inc. AII rights reserved.

CHAPTER 23 r Digestive System

47. Report 35

& crrr code(s):

& Icp-ro-cM code(s):

I& ICD-g-cM code(s):

\46. Report 39

& cpr code(s):

& rco-ro-cM code(s):

(& ICD-g-cM code(s):

& u"ur to decide number of codes necessary to correctly answer the questlon. Odd-numbered answers are located ln Appendix B, whlle the ftrll answer key is only avallable ln the TEACE Instructor Resources on Evolve.

Copyright @ 2015 by Saunders, an imprint of Elsevier Inc. A11 rights reserved.

APPENDIX A r Reports

and cltobrush was then used to obtain cervical curetting. The endocervical os was unable to be demonstrated by the Pipelle curette or the uterine sound. The cytobrush was then used to locate the central endometrial canal, and the Pipelle curette was then used to obtain endometrial curetting. Bimanual examination shows the uteruS to measure 4to 6 weeks, antevefted, smooth, mobile. Adnexa negative. Rectal declined. BUS within normal limits.

IMPRESSION: Clear cell carcinoma of unknown origin.

PLAN: Refer the patient to the University of Minnesota for diagnostic workup and treatment. The patient and University of Minnesota will be advised of the results of the biopsies when they become available.

PATHOLOGY REPORT LATER INDICATED: See Report 54.

PREOPERATM DIAGNOSIS: Atelectasis of the right lower lobe, suspecting either a mucous plug or obstructing cancer.

posToPERATM DIAGNOSIS: Mildly inflamed airways with some thick secretions. No definite mucous plug was seen, and certainly no cancer was noted.

PROCEDURE PERFORMED: Bronchoalveolar lavage, bronchial brushings, and bronchial washings.

For a detail of drugs used and amounts of drugs used, please refer to the bronchoscopy report sheet.

The patient was in the ICU on the ventilator, intubated, and so we simply used ICU sedation. We put the bronchoscope down the endotracheal tube. We could see the trachea, which appeared okay. The carina appeared normal. In the right and left lungs, all segments were patent and entered, and in the right lower lobe and middle lower lobe, there were increased, thick, tenacious secretions. No definite mucous plug. It did take a little suctioning to dislodge all of the mucus; however, it was not as bad as I thought it would be looking at the x-ray. The area was brushed, washed, and then, to be more specific, because of evidence on chest x-ray of something going on in the periphery/ a bronchoalveolar lavage of the right lower lobe is performed. The patient tolerated the procedure well. Specimens were performed. Specimens were sent for appropriate cytological, pathological, and bacteriological studies, and we hope to be able to follow up on that tomorrow.

PATHOLOGY REPORT LATER INDICATED: See Report 66.

PREOPERATM DIAGNOSIS: Chronic adenotonsillitis and chronic tonsillitis.

POSTOPERATM DIAGNOSIS: Chronic adenotonsillitis and chronic tonsillitis.

PROCEDURE PERFORMED: Tonsillectomy and adenoidectomy.

OPERATM NOTE: The patient is a 1S-year-old woman who was seen in the offlce and diagnosed with the above condition. Decision was made in consultation with the patient to undergo the procedure.

She was admitted through the same-day department and taken to the operating room, where she was administered general anesthetic by

Copyright @ 2015 by Saunders, an impdnt of Elsevier Inc. A11 rights reserved.

APPENDIX A I RCPOTTS

intravenous injection. She was then intubated endotracheally' The Jennings

gug *r, inserted into the mouth and expanded; this was secured to a Mayo stand. TWo red rubUer catheters were pliced through the nose and

brought

outthroughthemouth;theseweresecuredwithsnaps'Thiswasdoneto etevate th[ palate. A lar,rgeal mirror was placed in the nasopharynx' The

adenoid tissue was visuiliied. Using suction cautery, the adenoid tissue was

removed in systemic fashion. oncJthis was completed, the- red rubbers were

i"f"ur.a and |rought out through the nose. fhe iight tonsilwas grasped - with an Allis forceps and retracied mediatly using a harmonic scalpel, and

thecapsulewasenteredbilaterally.Thetonsilwasremovedfromitsfossain an inferior fashion, and one ,-uil ut"u was cauterized. The left tonsil was lfr"., grurp"d with u.r atnt forceps and retracted medially. Again, the capsule

was identifled laterally, and the.harmonic scalpel was used to remove the

tonsil from its fossa in an inferior to superior fashion' Once this was

.o*praraa, the bed was inspected, and -two

small areas wele cauterized here'

Three tonsillar sponges weie soaked in 1o/o Marcaine with epinephrine; one

was placed in the ,rulropt ury.r, and one in each tonsil bed. These were left

in p6sition for 5 minuier, u.td at the end of this interval they were remcved'

The beds were inspected. No further bleeding was noted. The gag was then

removedfromthemouth.TheTMJjointwaschecked.Thepatientwas allowed to recover from a general anesthetic and taken to the post

anesthesia care unit in stadle condition. There were no complications during this Procedure'

PATIIOLOGY RBPORT LATER INDICATED: Benign tonsil and adenoid

tissue.

PRE0PERATIVE DIAGN0SIS: Pleural fluid, unknown cause.

PoSToPE,RATIVEDIAGNOSIS:Loculatedpleuraleffusionwithremoval of 40 cc of bloodY Pleural fluid.

PROCEDURE PERFORMED: Diagnostic thoracentesis'- -o, ultrasound, the areas were lolulated by that method as well as by

attempting to draw out fluid. I had to do four different sticks to get 40 cc

of fluid and that was about the extent of each pocket' T,here were four

&i;;;;fi;.tJr r entered just in the one general area that was marked by ,iirurorrrrO. This, of courr., *u, done after marking it with ultrasound' i.rU5i.tg the area with swabs to sterilize the area, and then using 20 cc of

1olo

ilOo.iii" for loca1 anesthesia. With a one-pass maneuver, we were able to get into some fluid. At flrst actually, we did not get anf f-igi{' We moved

overaboutlinch,andthen*"*t'"abletogetlOccoffluidbeforethe po.i."ipu*"red oui. The next one we got 5 cc, and I had to go to a different 'nocket io set that. Then in the fourth pocket we were able to get two

;rr;;;.fufit *irt 10 cc to get at least-4b cc of fluid' As this was such a tl*J"r area, I did not put"a chest tube in to drain it because I did not think we would get ffining that would amount to anything with the r*ili.t.tt tube"I had at -y-.o-*und' I think we might need tfroir.oi.opy to break up adhesions and drain it right' Of course' the

differentiaiof Utooay pleural fluid includes tuberculosis, ttauma, cancer,

""Jp"f*"nary embol-us. A ViQ scan would probably be pointless in this

pu*i."fur effoit. I think I would wait to see *hat the cultures are before

i*.rt oo*n the pulmonary embolus tree. I wili have to get a hold of Dr. Marrot about CT surgerY'

PATH0LoGYRE,PoRTLATERINDICATED:SeeReport67.

Copyright O 2015 by Saunders, an imprint of Eisevier Inc' A1l rights reserved'

APPEND1X A r Reports

rNDrcATroN: This is a 46-year-old white male with rourette,s and some MR who has had some hematochezia. There are no risk factors with no other symptoms.

PREoPERlrrrvE MEDTGATTONS: Fentanyl 100 mcg I[ versed 4 mg IV. FTNDTNGS: The Pentax video colonoscope was inserted without difficulty to the cecum. The ileocecal valve was identified. The appendiceal orifice was seen. I could not enter the cecum. Just above the valve, there was a small 2- to 3-cm polyp. This was hot biopsied off. There was a sessile 3-mm polyp in the proximal ascending colon, hot biopsied off. Inspection of the remainder of the ascending colon, hepatic flexure, transverse colon, splenic flexure, descending colon, and sigmoid colon, revealed no erythema, ulceration, exudate, friability, or other mucosal abnormalities. The rectum showed a small Z-mm polyp that was hot biopsied off. The patient tolerated the procedure well.

TMPRESSTON: Three small polyps, two in the cecum ascending colon area and one on the rectum, hot biopsied off.

PLAN: If these polyps are adenomatous/ the patient should return again in 5 years for surveillance.

PATHOLOGY REPORT LATER INDICATED: See Report 56.

PREOPERATM DIAGNOSIS: Nonhealing duodenal ulcer. POSTOPERATM DIAGNOSIS: Nonhealing duodenal ulcer. PROCEDURES PERFORMED:

1. Exploratory laparotomy. 2. P artial gastrectomy (antrectomy). 3. Truncal vagotomy. 4. Gastrojejunostomy. 5. Cholecystectomy with intraoperative cholangiogram. rNDrcATroN: The patient is a 60-year-old female who presented with a nonhealing gastric ulcer. She has had symptoms for about a year. She complains of epigastric pain. Medical therapy with prilosec failed, as did therapy for H. pylori. Biopsy of the ulcer has been done, and it was benign. The patient had a negative workup for gastrinoma. calcium level was also normal. The patient now presents for exploratory laparotomy and partial gastrectomy. The risks and benefits were discussed with the patient in detail. She understood and agreed to proceed.

PROCEDURE: The patient was brought to the operating room. Her abdomen was prepped and draped in a sterile fashion. A midline umbilical incision was made. The peritoneal cavity was entered. Initial inspection of the peritoneal cavity showed normal liver, spleen, colon, and small bowe1. There was an ulcer along the first portion of the duodenum just beyond the pylorus with some scarring. There was also an ulcer in the posterior part of the duodenal bulb, which was penetrating to the pancreas. we started dissection along the greater curvature of the stomach. vessels were ligated wrth 2-0 silk ties. There was an enlarged lymph node along the greater curvature of the stomach, which was sent for frozen section. It proved to be a benign lymph node. This was the only enlarged node found during dissection. we then proceeded with truncal vagotomy. The anterior r,agus

Copyright @ 2015 by Saunders, an imprint of Elsevier Inc. A11 rights reserved.

APPENDIX A .r Reports

and posterior vagus were identifled. They were clipped proximally and

distaily, and a segment of each nerve was excised and sent for frozen

section, and a segment of both vagus nerves was excised and confirmed by

frozensection. An incision was made around the gastrohepatic ligament'

The mesentery along the lesser culvatule of the stomach was dissected.

The vessels were ligited with 2-0 silk ties along the lesser-curvatule of the

stomach. A Kocheimaneuvel was performed to aid mobilization. The

pancreas was completely normal. No masses were found in the pancfeas.

tfr"r. was penetraiion of the ulcer in the superior part of the head of the pancreas. iissection was continued posterior to the stomach. The adhesions

iosterior to the stomach were taken down. The ulcer was in the posterior

i"grrr.rrt of the duodenal bulb iust beyond the pylorus and it had pJnetrated the pancreas. All the posterior layer of the ulcer that was left

idherent to the pancreas was shaved off. The stomach was divided with

ift" Cn stapler * tttut the complete antrum would be in the specimen. The duodenum was divided betweert clamps. The stomach pylorus and

f,rst part of the duodenum were sent to pathology for-examination' Then

the duodenal stump was closed with running suture. Using 3-0 Lembert

sutures, the posterior wall of the ulcer was incorporated for duodenal

closure. The^base of the duodenum was rolled over the ulcer, and it was all-incorporating to the duodenal closure. Our next step was to proceed

with cholecysteitomy. The galibladder was separated from-the liver,

reflected, and taken do*r, ind the gallbladder was divided from the liver with blunt dissection and cautery. The cystic altely was doubly ligated

with silk. The cystic duct was identified. The cystic duct and gallbladder junction and gittbtadder ducts were identified. Intraoperative thoiangiogram was performed showing free flow of bile into the

intrahJpatlc duct ur'd i.rto the duodenum. No leaks were seen. The cystic

duct wis doubly ligated, and the gallbladder was sent to pathology. The

staple line in the pioximal stomaih was oversewn with 3-0 silk Lembert ,rtirr.r. A retrocoiic isoperistaltic Hofmeister-t)?e gastrojejunostomy was performed on the remaining stomach and loop of ieiunum. This was an

isoperistaltic end-to-side two-layer anastomosis with 3-0 chromic and 3-0 silk. The stomach was secured to the transverse mesocolon with several interrupted silk sutures to prevent any herniation along the retrocolic space. The anastomosis had a good lumen and good blood supply. There was no twist along the anastomosis. Before the anastomosis was finished, a nasogastric tube was placed along the afferent limb of the jejunum to decompress the duodenum and prevent blow out of the duodenal stump. Extra holes were made in the NG tube to provide adequate drainage. The anastomosis was marked with two clips on each side, and a Jackson-Pratt drain was placed over the duodenal stump. The peritoneal cavity was irrigated until clear. Hemostasis was adequate. The fascia was then closed with interrupted 0 Ethibond sutures. Skin edges were approximated with staples. Subcutaneous tissues were irrigated before closure. Estimated blood loss throughout the procedure was 200 ml. IV fluids: 3400 mI. Urine output: 840 ml.

FINDINGS: 1. Nonhealing benign ulcer in the posterior duodenal bulb penetrating into

the head of the pancreas. 2. Pafiial gastrectomy (antrectomy performed) and excision of the pylorus,

flrst portion of the duodenum along with ulcer. 3. Hofmeister-type retrocolic isoperistaltic gastrojejunostomy. 4. Posterior wall of the ulcer that was penetrating into the pancreas

incorporated into closure of the duodenal stump.

Copyright @ 2015 by Saunders, an imprint of Eisevier Inc. AII rights reserved,

APPENDIX A r Reports

6.

5.

7.

Truncal vagotomy performed with intraoperative frozen section conflrming both vagus nerves. Cholecystectomy pedormed due to chronic cholecystitis with normal intraoperative cholangiogram. Jackson-Pratt drain placed over the duodenal stump.

The items that are to be coded are listed below:

Partial gastrectomy (antrectomy) with gastroieiunostomy Truncal vagotomy Cholecystectomy with intraoperative cholangiogram

PATHOLOGY REPORT LATER INDICATED: TiSSUC ShOWCd NO CV1dCNCC of carcinoma. The radiologist reported the x-ray with 74300.

PREOPERATIVE DIAGNOSIS: Fournier's gangrene.

POSTOPERATM DIAGNOSIS: Fournier's gangfene, gastric foreign bodies.

PROCEDURI,S PERFORMED:

1.

2. 3.

Exploratory laparotomy with gastrotomy and removal of gastric foreign body. Placement of 1S-French Moss gastrojeiunostomy feeding tube' Diverting end-sigmoid colostomy (Hartmann's procedure).

ANESTIIESIA: General.

INDICATIONS: This is a 33-year-old patient with Fournier's gangrene who presents today for a diverting colostomy due to wound care and placement of a gastrostomy tube for help with further follow-up feeding.-He

presents today for exploration. The family understands_the risks of bleeding, infection, and postoperative fluid collections and wishes to proceed.

PROCEDURE: The patient was brought to the operating room, placed under general anesthesia, and prepped and draped with Betadine solution. A midline incision was made with a #10 blade and dissection was carried down through subcutaneous tissues using electrocautery. The midline fascia was identified and divided. The posterior sheath and peritoneum were sharply incised, thus allowing ently into the peritoneal cavity. There was some free fluid within the peritoneal cavity but no evidence of any abnormalities. We first identified the stomach and could feel what we felt were some polyps in the stomach. We first placed concentric purse-string , sutures along ttre greater curvature of the stomach, opened up the stomach, and then paised an 18-Frettch Moss gastrojeiunostomy tube but were unable to get it down through the pylorus. We could feel these multiple masses in the stomach. We tied the purse-stfing sutules and inflated the balloon. we then made a small opening in the stomach with electrocautery and retrieved about 20 large what appeared to be vegetable matter and partially digested peppels and pickles. We irrigated with saline and then were able to pass the voss gastroieiunostomy tube, the distal end, down through the pylorus. we closed the gastrotomy with a running 3-0 vicryi and an outer iayer of 3-0 silk Lembert sutures. We irrigated this area well. We then identified the sigmoid colon, fired a TLC-75 stapler across the sigmoid/ descending colon, and then placed a 3-0 Prolene on the rectal stump. We

Coplright @ 2015 by Saunders, an imprint of Elsevier Inc. A11 rights reserved'

CHAPTER 24 t lJtinaty and MaIe Genital Systems

PRA(TICAL

using the cPT and ICD-10-CM/ICD-9-CM manualq code the following:

{8. Erdorcopy for resection of primary malignant renal pelvis tumor through an established stoma.

ICD-10-CM Code:

(ICD-9-CM Code:

59. Aspiration of a solitary, non-congenital renal cyst through Percutaneous needle.

CPT Code:

ICD-1.0-CM Code:

(ICD-9-CM Code:

/60. ,Jr"teroureterostomy performed for urinary tract obstruction.

CPT Code:

ICD-IO-CM Code:

(ICD-9-CM Code:

61. Transurethral incision of the prostate to fteat benign hypertrophic prostatitis.

CPT Code:

ICD-IO-CM Code:

(ICD-9-CM Code: )

,d. Cyrtourethroscopy due to intermittent hematuria'

CPT Code: 5TNO Q ICD-10-CM Code:

(ICD-9-CM Code:

63. Abdominal orchiopexy to release undescended intra-abdominal

CPT Code:

ICD-10-CM Code:

(ICD-9-CM Code:

odd-nunbered answers are located in Appendlx B, while the ftrtl answer key ls only available tn the TEACE

Instructor Resources on Evolve.

copyright @ 2015 by Saunders, an impdnt of Elsevier Inc. A11 rights reserved.

CHAPTER l,Q t Uinary and Male Genital Systems

67.

1.

7t.

J,,

/ & CPr code(s); '1121 O JrO. *Uu,"ral shunt of corpora cavernosa-saphenous vein for priapism.

& cpr code(s): St{L{ >0 Vasovasorrhaphy.

& cpr code(s):

Exposure of the prostate for insertion of radioactive substance.

& cpr code(s): sLB 6 0 73. Surgical reduction of torsion of testis with fixation of contralateral

testis.

& cpr code(s):

& U""r to decide number of codes necessary to cofrectly answer the question. Odd-numbered answers are located ln Appendlx B, while the full answer key is only available in the TEACE

Instructor Resorrrces on Evolve.

,C. ao nlicated prostatotomy of prostate cyst.

CPT Code: -q514-5 ICD-1O-CM Code:

(ICD-9-CM Code:

65. Closure of nephrocutaneous fistula.

CPT Code:

I JOe . L steroid injection for urethral stricture using a cystourethroscope.

& cvr code(s): 5.:'aB 3 Total urethrectomy of a 44-year-old male.

& cpr code(s):

Circumcision using clamp, routine.

& cpr code(s): 5Lil m-5; & tco-ro-cM code(s):

1& rco-o-cM code(s):

69. Excision of Skene's glands.

Copyright @ 2015 by Saunders, an imprint of Elsevier Inc' All rights reserved'

,r' CHAPTER 24 : Utinary and MaIe Genital Systems

t/+. Oittut hypospadias repair with chordee using a V-flap advancement,' completed in one stage.

& cprcode(s): 5Y);L>- 75. Simple destruction of four lesions of the penis using cryosurgery'

& cpr Code(s):

46. Repair of an incomplete circumcision.

& cpr code(s): 5ttt f 3 77. Drainage of a scrotal wall abscess.

,& cpr code(s):

4f . ,r"r"rectomy, with repair of the bladder cuff. & cpr code(s): 50b 50

9 User to decide number of codes necessary to correctly answer the questlon. Odd-numbered answers are located in Appendlx B, while the full arlswer key is only available ln the TEACE Instnrctor Resources on Evolve.

Coplright O 2015 by Saunders, an imprint of Elsevier Inc. A1l rights reserved.

CH.\PTER 2-1 r Lrinar)' and \fale Genital Systems

REPORTS

In Appendix A of this workbook yolt wilr find a section titlecl Reports, which contains original reports. Reod the reports indicated below and sttpply the appropriate cPT and ICD-10-]M|ICD-9-]M codes on the followiig lines:

79. Report 36

., d, Cf,f Code1s.1: r'Bo. Report 37

sb CpT Code(s):

& tco-to-cM code(s):

(& rcD-g-cM code(s):

81. Report 38

CPf Code(s):

1,

.B ICD-10-CM Code(s):

(,:s ICD-9-CM Code(s):

Report 81

bb cpr Code(s):

Report 82

& cpr code(s):

Report 83

&, CPf Code(s):

&, ICD-iO-CM Code(s):

(&'] ICD-9-cM code(s):

85. Report 84

& cpr code(s):

i-*' ur"" to decide numtrer of codes necessary to correctly answer the question. odel-numbered answers are located in Appendix B, while the full answer key is only available in the TEACH Instructor Resources on Evolve.

83.

Copyright @ 2015 by Saunders, an imprint of Elsevier Inc. Al1 rights reserved

APPENDIX A r RCPOTtS

without any complications. KUB was then done demonstrating the tip of the CORFLb i., ttt. third portion of the duodenum' After confirmation of postpyloric position of the CORFLO, the patient was started on Ultracal at 10 cc/hr.

PREOPERATIVE DIAGNOSES:

1. Expressed desire of the operating gynecologist to insert indwelling ur6teral stents for ease of dissection of the anticipated enlarged adherent uterus.

2. Gynecologic diagnosis of pelvic endometriosis.

POSTOPERATM DIAGNOSES: Same. pRocEDURE PERFORMED: Cystourethroscopy, insertion of bilateral ureteral catheters.

PROCEDURE: After general anesthesia and after the abdomen and genitalia had been prepped and draped in the usual fashion, the patient was

itaceA in the Aorsotitfrotomy position. The genitalia were examined and proved to be essentially unremarkable. The urethra was instrumented with a 2q-French panendoscope sheath, and, using the foroblique and right-angle lenses, insfection of the entire vesical cavity showed no indication of any pathologiC lesion. There is slight indention and some of the bladder incidenito the uterine impression. The two ureteral orifices appear to be essentially unremarkable. The left ureteral orifice was catheterized with a 6-French Whistle Tip catheter with ease. The catheter was advanced to approximately 25 cm on the left side. Attention was then directed to the ,igit tid", and the right ureteral orifice was catheterized with a 6-French V,ifrlrtt. Tip catheter. The catheter was placed at approximately 24 cm. The bladder wis then entered, Panendoscope sheath was withdrawn' A 18-French 5-mt balloon Foley catheter was then inserted into the bladder and left indwelling to the Foley catheter. The two uleteral catheters were anchored with 4o- t black silk. The two ureteral catheters and the Foley catheters were then connected to straight drainage and the patient was removed from the dorsolithotomy position. Dr. Weasly, the patient's gynecologist, then proceeded with a total abdominal hysterectomy and bilateral salpingo-oophorectomy.

PREOPERATM DIAGNOSIS: Recurrent transitional cell carcinoma of the bladder.

POSTOPERATIVE DIAGNOSIS: Same.

PROCEDURE PERFORMED: Cystoscopy; multiple random bladder biopsies.

CLINICAL NOTE: This patient has recurrent transitional cell carcinoma of the bladder. He has had BCG bladder instillation to help prevent recurrence. His last instillation was 6 weeks ago. The patient is doing welI. He denied any complaints.

PROCEDURE: The patient was given a general endotracheal anesthetic and prepped and draped in lithotomy position. A 24-French resectoscope

Copydght @ 2015 by Saunders, an impdnt of Elsevier Inc. All rights reserved'

APPENDIX A T REPOTTS

waspassedintothebladderunderdirectvision.Theurethrawasnormal. prostate was nonobstructed. Inspection of the bladder demonstrated

areas of

hyperemia that would be most ionsistent with BcG changes but might also

represent recunent ICC. These afeas wele biopsied using a cold-cup biopsy'

A 24-French ,es"ctoicope ioupe was then used to cautedze these areas.

Ureteric oriflces were identified. Clear urine could be seen effluxing

bilaterallY. The patient tolerated the procedure well' A B&O suppository was

placed

,".iuiry uft"r the end of the irocedure. An 18-French Foley catheter was

prr."i," r,raight o*i"ug". Bimanual examination showed no significant itrnormality and the prostate felt normal'--ifru

prti"nt will bJscheduled for recheck cystoscopy in three months

time providing pathology shows no evidence of recurrent tumor'

ADDENDUM:TotalresectedandfulguratedareaofthebladderwasT square centimeters.

PATIIoL0GYREPoRTLATERINDICATED:SeeReport55.

PREOPERATM DIAGNOSIS: Urinary incontinence'

POSTOPERATM DIAGNOSIS: Same'

pRocEDURE PERFORMED: Insertion of double cuff artificial urinary

iphincter with 25 cc reservoir (multicomponent)'

CLINICAL NOTE: This patient has had radiation for prostate cancer' This

recurred.Hethenrradcryothelapy.HisPSAisundetectablebuthehas significanturinaryincontinenceunresponsivetopharmacotherapy.External climp devices have been unsatisfactory'

pRocEDURE, NOTE: The patient was given a spinal anesthetic, prepped

and draped in a supine position. A penoicrotal incision was made' A l-6-

F;;.h ioley was ptaced in the bladder to straight drainage.-The urethra was dissected to the level 0f the bulb. The bulbocavernous muscle

was very

atrophic and was not dissected off the urethra. A double cuff placement was

selected. The urethra was mobilized in two places with a small bridge of

tissue between them. These cuffs were incised. Both were incised at 4'5 cm'

A reservoi*pu." *u, .r"rl"A by manual dissection in the left inguinal canal into the retropubic space. The ieservoirr'vas placed' cycle.d, and

filled with

25 cc of sterile saunll Both cuffs were placed in the usual fashion. The

,"rp was then placed in the mid-scrolal pouch. connections wete made

usingaYConnectorandstraightconnectorsintheusualfashion.The ;y;,.h was cycled; it worked iarell. Foley catheter was withdrawn to insure .y.ri"g appropriateiy. Subcutaneous tisiues were closed with 3-0 chromic and skin with a 4-O'subcuticular Vicryl stitch' The pumprvas cycled

,g"i" ""a then deactivated; the Foley catheter replaced. The patient

tolerated the procedure well and wai transferred to the Iecovery toom in

s;J.."oition. rrre wounds were thoroughly irrigated with Baciftacin

solution.

PREOPERATM DIAGNOSIS: Morbid obesity'

POSTOPERATIVE DIAGNOSIS: Same'

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APPENDIX A r Reports

This 49-year-old presents with dyspnea. He has previous cigarette smoking history.

COMPLETE PULMONARY FUNCTION STUDY: Forced vital capacity is 4.87 L, \l2o/o of predicted. FEV1 is 4.O2 L, 713o/o of predicted. FEV1 is 830/0. FEF 25o/o to 7 5o/o is normal. There is no significant response to bronchodilators. Flow volume loop shows a well-preserved inspiratory limb.

Total lung capacity by plethysmography is 6.82L,1,1,1,o/o predicted. RV/ TLC ratio and airway resistance are normal. Corrected DLCO was 18.99, 7Oo/o of predicted.

IMPRESSION:

1. Normal expiratory flow rates. 2. Normal lung volumes. 3. Mild reduction of DLCO is noted. The cause of decreased diffusion capacity is unclear in this patient. Possible causes could include heart disease, pulmonary embolism, anemia, obstructive sleep apnea. Clinical correlation is advised for cause of abnormal diffusion. There is no evidence of coexisting obstructive or restrictive pulmonary disease.

Note: The items to be coded listed below: . Spirometry before and after bronchodilator . Respiratory flow volume loop o Functional residual capacity . Carbon monoxide diffusing capacity . Bronchodilator supply

PREOPERATM DIAGNOSIS: History of adenocarcinoma of the prostate.

POSTOPERATM DIAGNOSIS: History of adenocarcinoma of the prostate.

PROCBDURES PERFORMED:

1. Transrectal ultrasound performance with: 2. Volume study. 3. Needle iocalization. 4. Needle implantation 5. Cystoscopy. ANESTHESIA: General.

ESTIMATED BLOOD LOSS: Minimal.

PROCEDURE: Please see the preoperative note for indications of the procedure, as well as full informed consent. The patient underwent a general anesthetic and was put in the extended dorsal lithotomy position. The table was decanted or in Trendelenburg 5 degrees. He was prepped and draped in the usual fashion, which included a 14-French Foley catheter with 72O ml of sterile saline in his bladder. The testicles and scrotum had been taped back and away. We irrigated the rectum with sterile saline, performing

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APPENDIX A r Reports

a pseudo-enema. The patient underwent transrectal ultlasound placement. Tliis was connected to the gantly. The placement of ultrasound and the grid work were set up so that the base of the plostate is noted at #1 on the grid work. The anterior most component at approximately 4.5-5, prostate extended from side-to-side from A to F.

Five-mm increment imaging slices were obtained, starting at the base of the prostate, carrying it back for a total of 3 cm to 30. Volume of the prostate is approximately 33 ml.

The outline of the prostate was drawn during the volume study. This information was given to the computer electronically so that a plan could

, be developed. Once the plan had been completed, the placement of the needles was performed in the usual fashion. The dose was delivered via \25 seeds afLer placement of the needles.

The total number of needles was 41 for 107 seeds (radioelements) placed with ultrasound guidance. The patient tolerated this well. At the conclusion, the patient was re-prepped and draped with the Foley catheter being removed and a cystoscopic evaluation was performed. There is no evidence of perforation of the urethra, bladder neck, or bladder. Urine within the bladder was clear. No seeds oI spacers could be identified. An 18-French Foley catheter was then placed along with Triple antibiotic salve to the perineum and mesh panties. He tolerated the procedure well overall. Estimated blood loss minimal.

PREOPERATM DIAGNOSIS: History of a nodular mass, mid-prostate with urinary retention.

POSTOPERATM, DIAGNOSIS: History of a nodular mass, mid-prostate with urinary retention; possible macronodular prostate.

PROCEDURE: Cystoscopy, transurethral resection of the prostate, one stage.

ANESTHESIA: Spinal.

ESTIMATED BLOOD LOSS: Approximately 100 ml.

FINDINGS: Benign prostatic hlpertrophy type changes. This is a 76-year-old gentleman who has a history as outlined in the

preoperative note. Cystoscopically there is a large, red, macronodular area along the base of the prostate, which has been noted. The patient is having outlet obstructing symptoms. He has some decompensation in his urinary bladder but in discussion with the findings he wishes to go through the transurethral resection of prostate as outlined and discussed.

The patient underwent a spinal anesthetic, was put in the dorsolithotomy position, prepped, and draped in the usual fashion. Cystoscopic evaluation reveals the 1-cm nodule along the base of the plostate. This appears more macronodular but is not really prostatic or is very minimally prostatic. It could represent a deteriorating median lobe.

Resection of the prostate was started at the 12-o'clock position and was carried between 3 and 9 o'clock back to the plane of the verumontanum. The base tissue and the rest of the lateral walls were then resected. This was a pretty small prostate, around 20 ml of tissue. The area was separately resected.

At the conclusion of this procedure, the chips were irrigated out of the bladder. Final hemostasis was achieved. A 22-French three-way Foley

Copyright @ 2015 by Saunders, an imprint of Elsevier Inc. A11 dghts reserved.

APPENDIX A r Reports

catheter was inserted, inflated, and irrigated with slightly tinged irrigant

returning. He was taken to the Recovery Room in satisfactory condition'

ANESTIIBSIA: General. Pleaseseethepreoperativenoteforindicationsoftheprocedureaswell

as full informed ionsent. This L4-year-old was recognized on a sports physical as having a nonpalpable iesticle' Through his younger years' it had been palPable.

rhe testicle on physical exam sat in the superficial inguinal canal next to

the external ring. Witfr nim asleep, we went ifreaO and evaluated again and,

alain, the testicirlar cord was foreJhortened, not allowing the testicle to get

into the scrotum proper and sat slightly lateral as noted on the preoperative

note. Heunderwentagenelalanestheticasnotedpreviouslyandwasprepped

and draped in the ulual fashion. A transverse incision was made halfway

between the anterosuperior iliac spine and pubic tubercle at the presumed-

location of the internil ring. The ixternal oUtique aponeurosis was opened

uio"g the course of its fiberi to the external ring. The inguinal canal was

open"ed.Theexternalilioinguinalnervewasidentifiedandpreserved.The testicle could be identified 6utside the inguinal canal lateral to it in its own

small covering. This was opened and the cord, with the testicle, could be

freedup.Weremovedsomeoftheadhesionsalongthecord,whichallowed ,r*y ,uiirfuctory length to allow it to fit well into the inferior aspect of the left hemiscrotum.

A separate incision was made in the left hemiscrotum. subdartos pouch

was foimed using sharp and blunt dissection. The testicle was brought

through in a meiial trict performed by using blunt dissection with a hemostat. The testicle was brought down into the sclotum and out of the

incision with ease. on the inferior pole of the testicle, a small 3-0 chromic was placed in the inferior most poriion of the septum. The _scrotal wall was

then closed over the testicle with interrupted 3-0 chromic. iffigation of the-

wound was performed. No active bleeding.ou,lg be identified. The external

oblique apoireurosis was closed utilizing 3-0 silk. BupivacaineO.25o/o withtut epinephrine was placed approximately 3 ml in the internal ring and 3 ml in the subcut. The subcul was closed with interrupted 3-0 chromic and 4-0 undyed vicryl for subcuticular incision closure with steri-Strips' He

tolerated the Procedure well.

The procedure was performed in the usual fashion and multiple segments as

noted. Transrectal ultrasound was performed with the patient in the left lateral

position. The ultrasound is performed in order to evaluate the prostate in

hetail, bladder neck, and seminal vesicles. Ultrasound shows a width of the

p'o'tut"at45mm.Theentirecalculatedvolumeoftheprostateis lpproximately 40 cc,s. Large amount of the bladder neck/median lobe is

noieO as prominent. No other f,ndings are noted in the prostate'

PREoPE,RATIVE, DIAGN0SIS: History of left cryptorchid testicle.

POSTOPERATM DIAGNOSIS: Left ectopic testicle'

pRocBDURE PERFORMED: Left groin exploration with orchiopexy'

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CHAPTER 25 r Reproductive, Intersex Surgery, Female Genital system' and Matemity Care and Delivery

PRACTICAT

tJsing the CPT manual, code the following:

53. Dilation of the vagina under anesthesia'

*d Plastic repair of a urethrocele'

cPr code: 51)30 55. Labial adhesions lYsis.

CPT Code:

,d." ,r^ple complete vulvectomY.

cPr code: Sbb&, 57. Surgical hysteroscopy with polypectomy and dilatation and curettage.

CPT Code:

1258. Transposition of the left ovary.

cPr code: 33879 ' ef Bilateral wedge resection of ovaries.

CPT Code:

rdO. therapeutic amniocentesis with amniotic fluid reduction.

CPT Code: .qqRO I

61. Drainage of a cyst of the left ovary using the vaginal approach'

& cpr code(s):

42. Surgiral treatment of a second-trimester missed abortion'

& cpr code(s): ,rq E r- t 63. Cesarean delivery onlY.

& crr code(s):

T. uyrterorrhaphy of a ruptured, pregnant uterus.

& cpr code(s): 5q 3 5 0

& u""t to decide number of codes necessary to correctly answer the question. Odd-numbered answers are located in Appendlx B, while the ftrll answer key is only available in the TEACE Instructor Resources on Evolve.

Copyright @ 2015 by Saunders, an imprint of Elsevier Inc. A11 rights resewed.

59.

CHAPTER25IReploductive,IntefsexSurgeryFemaleGenitalSystem,andMatemityCareandDelivery

65. Fetal contraction stress tests/ antepartum'

& cPr code(s): ,{)

/oe. xuairal vaginal hysterectomy'

& cpr code(s): JC '8i 67. Marsupialization of Bartholin's gland cyst'

/ & cPr code(s): y'eg. nxcision of BartExcision of Bartholin's gland.

& cpr code(s):

Destruction of extensive vaginal lesions'

& cpr code(s):

& U""t to decide number of codes necessary to correctly answer the questlon. odd-numbered answers are located in Appendix B, while the firll answer key is only avallable in the TEACII

Instrrrctor Resources on Evolve.

69.

Copl'right@2015bySaunders,animpdntofElsevierlnc,Allrightsreserved.

CHAPTER25rReploductive,Intersexsurgery,FemaleGenitalSystern'andMatemityCareandDelivery

REPOBTS

In Appendix A of this workbook you will find a section titled Reports, which . contains originai reports' code only the p'ri1n6* sutgery' Read the report indicated

below and *piy ihe appropriate bpf ind ICD-10-CM/ICD-9-CM codes on the ,/ following lines: ,./,/ /'

4o. neport 20

& cPr code(s):

71. Report 28

& cpr code(s):

& tco-ro-cM code(s):

(& tcP-g-cM code(s): )

u/2. xeport zo

& crrr code(s):

& Ico-ro-cM code(s):

(& tco-g-cM code(s):

73. Report 30

& cpr code(s):

& lcp-ro-cM code(s):

(& Ico-q-cM code(s):

& U"". to decide number ofcodes necessary to correctly answer the questlon. Odd-numbered answers are located ln Appendix B, whlle the full answer key ls only avallable ln the

TEACE

Instructor Resources on Evolve.

copynight o 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved.

r5 ih

I ,1,

APPENDIX A r Reports

PROCEDURE: The patient was brought to the operating room and placed in the supine position, and under general intubation with a double-limen tube that had been placed the night before, the patient was rolled into the right lateral decubitus position with her left side up. A posterolateral thoracotomy was performed. Adhesions were taken down sharply and bluntly and with caut€ry. Following this, a standard artery nrsi tett upper lobectomy was carried out utilizing 0 silk and hemoclips. The left upper pulmonary vein was secured with a single application

-or trre TA-30 vascular

stapling machine. The posterior fissure was created with multiple applications of the TIA automatic stapling machine and the bronchus secured with a single application of the TA-30 bronchus stapling machine. Following this, the wound was drained with three 24-Frcnch atrium chest tubes and hemostasis obtained with spray Tisseel, Surgicel gauze. The bronchus was sealed with Bio-glue and the wound cloied in layers and a sterile compression dressing applied, and the patient returned io the surgical intensive care unit after changing the double-lumen tube to a single-lumlen tube. The patient received 3 units of packed cells intraoperatively to maintain hemostasis. sponge count and needle count correct x 2. PATHOLOGY REPORT LATER INDICATED: See Report 65.

Endocervical and Endometrial Biopsy The patient is a 60-year-old married white female, whose last menstrual period was at age 55. No postmenopausal bleeding. pap is current. Mammogram is not given.

CHIEF COMPLAINT: Metastatic clear cell carcinoma. The patient is status post cr-guided transgluteal biopsy of a presacral

mass, which returns as metastatic clear cell carcinoma.-Biopsy was performed September 17,2oxx. The patient's cr of the ab^domen shows the uterus to be slightly enlarged for patient's age but does not mention ascites or ovarian masses.

MEDICATIONS:

1. Citracal. 2. Lanoxin 0.25 mg. 3. Metoprolol 50 mg b.i.d. 4. Multivitamin. 5. Ocuvite. 6. Xanax.

MEDICAL PROBLEMS:

1. Chronic pelvic pain syndrome. 2. Sacroiliac lipoma. 3. Pudendal neuralgia. 4. Hiatal hernia. FAMILY HISTORY: Negative.

REVTEW oF SYSTEMS: positive for glasses, high blood pressure, anxiety, depression.

PROCEDURE: Endocervical and endometrial biopsy. The patient received antibiotic prophylaxis and ihen the procedure was

performed by visualizing the cervix. The cervix was prepped with Betadine,

copyright @ 2015 by saunders, an impdnt of Ersevier Inc. Arl rights reserved.

APPENDIX A r Reports

Tfi

and cltobrush was then used to obtain cewical culetting. The endocelvical os wa; unable to be demonstrated by the Pipetle curette or the uterine sound. The cytobrush was then used to locate the centlal endometdal canal, and the Pipelle curette was then used to obtain endometrial curetting. Bimanual exlmination shows the uterus to measure 4to 6 weeks' anteverted, smooth, mobile. Adnexa negative. Rectal declined. BUS within normal limits.

IMPRESSION: Clear cell carcinoma of unknown origin.

PLAN: Refer the patient to the university of Minnesota for diagnostic workup and treatment. The patient and University of Minnesota will be advised of the results of the biopsies when they become available.

PATHOLOGY REPORT LATER INDICATED: See Report 54.

PREOPERATM DIAGNOSIS: Atelectasis of the right lower lobe, suspecting either a mucous plug or obstructing cancer.

POSTOPERATM DIAGNOSIS: Mildly inflamed airways with some thick secretions. No definite mucous plug was Seen, and certainly no Cancer was noted.

PROCEDURE PERFORMED: Bronchoalveolar lavage, bronchial brushings, and bronchial washings.

For a detail of drugs used and amounts of drugs used, please refer to the bronchoscopy report sheet.

The patient was in the ICU on the ventilator, intubated, and so we simply used ICU sedation. We put the bronchoscope down the endotracheal tube. We could see the trachea, which appeared okay. The carina appeared normal. In the right and left lungs, all segments wete patent and enteled, and in the right lower lobe and middle lower lobe, there were increased, thick, tenacious seiretions. No defrnite mucous plug. It did take a little suctioning to dislodge all of the mucus; however, it was not as bad as I thought it would be looking at the x-ray. The area was brushed, washed, and then, to be more specific, because of evidence on chest x-ray of something going on in the periphery a bronchoalveolar lavage of the right lower lobe is performed. The patient tolerated the procedure well. Specimens were performed. Specimens were sent for appropriate cytological, pathological, and bacteriological studies, and we hope to be able to follow up on that tomorrow.

PATHOLOGY REPORT LATER INDICATED: See Report 66.

PREOPERATM DIAGNOSIS: Chronic adenotonsillitis and chronic tonsillitis.

POSTOPERATM DIAGNOSIS: Chronic adenotonsillitis and chronic tonsillitis.

PROCEDURE PERFORMED: Tonsillectomy and adenoidectomy.

OPERATIVE NOTE: The patient is a 1s-year-old woman who was seen in the offlce and diagnosed with the above condition. Decision was made in consultation with the patient to undergo the procedure'

She was admitted through the same-day department and taken to the operating room, where she was administered general anesthetic by

Copyright O 2015 by Saunders, an imprint of Elsevier Inc' A11 rights reserved.

APPENDIX A r Reports

descent of the fetal head had been achieved. Baby then delivered and was a live-born male infant. (report one liveborn with a V code) There was moderate shoulder dystocia present (supports delivery complicated by shoulder presentation) and this was relieved with McRobert's maneuver. The baby was handed off to the NICU team and is currently in the NICU for further observation. Apgar's (a newborn maturity scoring method) are not available at this time. Cord blood gas is also pending. After an episiotomy, a second- degree perineal tear stil occurred during delivery. (for ICD-9-CM, report delivery complicated by second degree laceration of perineum with fifth digit " 1" to indicate the complication occured at the time of delivery) This was repaired using 3-0 chromic in usual manner. The patient tolerated this procedure well. Estimated blood loss during delivery was 200 cc.

PREOPE,RATIVE DIAGNOSES:

1. Intrauterine pregnancy, 39 weeks. 2. Multiparity. 3. Desires permanent sterilization. 4. History of previous cesarean section x 2.

POSTOPERATfVE DIAGNOSES:

1. Intrauterine pregnancy, 39 weeks. 2. Multiparity. 3. Desires permanent sterilization. 4. History of previous cesarean section x 2.

PROCEDURE: Repeat low transverse cervical segment cesarean section with postpartum tubal ligation.

ANESTIIESIA: Spinal.

ESTIMATED BLOOD LOSS: 800 cc

URINE OUTPUT: 40 cc

FLUIDS: 3OO0 cc

COMPLICATIONS: None.

FINDINGS: Viable male infant (eport the outcome of delivery) weighing 6 pounds 10 ounces with Apgar's of 9 at 1 minute and 10 at 5 minutes.

PROCBDURE: The patient was prepped and draped in a supine position with left lateral displacement of the uterine fundus. Under spinal anesthesia and Foley catheter indwelling, a transverse incision was made in the lower abdomen using the old scar. The fascia was divided laterally. Rectus muscles were divided in the midline. The peritoneum was entered in a sharp manner. The incision was extended vertically. The bladder flap was created using sharp and blunt dissection and reflected inferiorly. The uterus was entered in a sharp manner in the lower uterine segment, and the incision was extended laterally with blunt traction. The head was delivered, the infant was delivered, and the infant was bulb suctioned while the cord was being doubly clamped and divided. The infant was given to the intensive care nursery staff in good condition. The placenta was manually expressed. Uterus was delivered through the abdominal cavity and placed on a wet lap sponge. A dry lap sponge was used to ensure that the remaining products of conception were removed. The cervical os was ensured patent with a ring

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APPENDIX A r Reports

forceps. The uterus incision was closed.with 0 vicryr in an interlocking suture in two layers with second layer imbricating irr" ilrt. Figure_of_e'ight sutures were also praced as required for hemostrrlr. op"ruiive site wasinspected, i*igated, and hem6static. The bladder nrp Iru, i"rpproximated Ti"s 2-oYicryl in a continuous suture in the midline. The reft tube wasidentified in its entirety,.including the fimbriated end ,.rd *u, grasped at itsmidportion and elevated.lhe meiosalpinx was transected using the Bovie.Approximately 3 cm of tube was isorat-ed and excised. irr. prorimal end ofthe distal portion and the distal end of the p.o*i*iip;;-,i";i",;iig;rJo"' with 0 chromic sutu-re. The right tube was identified ind rigated in the same, fashion. operative site was inipected and was hemostatic. irt".r, was placedback in the midabdominal .u,rity. pelvic gutters were irrigated. The anteriorperitoneum was reapproximated with z-o vicryl continu3us suture. rrreincision was_irrigated. Subcutaneous drain was praced, and the skin wasclosed with 2-0 silk. Sponges and needles were accounted for at thecompletion of the procedure. The patient refr the ;G;G;room inapparent good condition after toleiating the proced'ur. *"it. The Foleycatheter was patent and draining a small amount of clear urine at thecompletion of the procedure.

PREOPERATIVE DIAGNOSIS: COMPIiCAICd PTCgNANCY With PriOrcesarean sections.

PosroPERATrvE DrAGNosrs: complicated pregnancy with priorcesarean sections. (Z/.v code for history of obstetricil disorder'affectiig management of current pregnancy)

PROCEDURE ,ERFORMED: Amniocentesis for fetal lung matwity. (V code for screening, antenatal based on amniocentesis) -o

rNDrcATroNS: The patient is at 3T/r-weeks,gestation and has had threeprior c-sections and hospitalizations for recurrent episodes ofpyelonephritis. (Z/v c_ode for personal history a specified urinary system disorder)we desired to check fetd malurity so we could expedite delivery if possibre. PROCEDURE: The patient was scanned with urtrasound, and few pocketsof amniotic fluid were noted; therefore, we erected to do a suprapubic tap.The abdomen was prepped and draped. Dr. Mur.o elevated the breech of theinfant up out of the pelvis, and we icanned suprapuricariy and found a nicepocket of amniotic t"i9: A singre tap was aond and ro cc or clear yelrowfluid obtained. This fluid was crrecteo for pH and was oeepiy blue onNitrazine, indicating it to be most likery amniotic fluid, not urine. Shetolerated this well.

cytology rcport 1ater indicated slightly decreased fetar rung maturitybasedon levels of phosphatidylgryceior, *ith ,..o*mendation tore-evaluate in 10 days. (abnormil amnion, affecting fetus)

PREOPERATM DIAGNOSIS: Hematochezia. POSTO*ERATM DIAGNOSIS: Two smalt polyps in the cecumascending colon, hot biopsied off. A smal rectil p,irru, r.o, biopsied off,

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