Sample Surgery Reports for Medical coders

PREOPERATIVE DIAGNOSES: 1. Hallux valgus deformity.
  1. Pes planus with abnormal pronation.
  2. Hammertoe deformity, second and third digits.
  3. Gastrocnemius equinus, all left foot and leg.

POSTOPERATIVE DIAGNOSES: 1. Hallux valgus deformity.
  1. Pes planus with abnormal pronation.
  2. Hammertoe deformity, second and third digits.
  3. Gastrocnemius equinus, all left foot and leg.


OPERATIVE PROCEDURES: 1. Bunionectomy with hallux osteotomy.
  1. First metatarsocuneiform joint arthrodesis.
  2. Application of external fixation device.
  3. Gastrocnemius recession.
  4. Hammertoe correction, second digit.
  5. Hammertoe correction, third digit. 

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ESTIMATED BLOOD LOSS: Less than 50 cc.


DESCRIPTION OF PROCEDURE:

Sample Surgery Reports for Medical coders
The patient was brought into the operating room and placed prone on the gurney followed by administration of a popliteal block by the anesthesiologist. He was then placed supine on the operating table and placed under a state of general anesthesia. A pneumatic tourniquet was then applied to the left thigh and a supplemental anesthetic block utilizing 12 cc of 0.5% Marcaine plain was performed around the left forefoot. The left foot and leg were then prepped and draped in the usual sterile manner. The foot and leg were exsanguinated and the tourniquet was inflated to a pressure of 300 mmHg. Attention was then directed to the posteromedial aspect of the left leg where a 2-cm linear incision was made at the junction of the gastrocnemius and soleus muscle bellies.
Dissection was continued down to the deep fascia and a deep fascial incision was made. The interval between the gastrocnemius and soleus muscles was identified and then bluntly dissected from medial to lateral. Next, using the Integra endoscopic gastrocnemius recession system, probe, cannula and camera were then inserted in succession. The gastrocnemius aponeurosis was visualized from medial to laterally and with gentle dorsiflexion on the foot, a gastrocnemius recession was performed. Direct visualization of the recession was achieved through the endoscope. Adequate dorsiflexion at the ankle joint was achieved as well. The cannula and camera were then removed followed by the copious lavage, closure of the deep fascia, and layered closure of the skin. Attention was then directed to the dorsal aspect of the foot where an incision was made medial to the extensor hallucis longus tendon centered over the bunion deformity and extending to the DIP joint of the hallux. Using sharp and blunt dissection, the incision was deepened into the first intermetatarsal space down to and through the transverse metatarsal ligament. The adductor tendon was identified at its distal and lateral attachment. It was then freed distally and laterally, isolated proximally, and a 0.5-cm segment excised. The fibular suspensory ligament was then transected. A dorsolinear incision was then made centered over the first metatarsocuneiform joint and dissection continued down to the level of the deep fascia. A deep fascial and periosteal incision was made over the joint lateral to the extensor hallucis longus tendon and capsular structures were freed dorsally, medially, and laterally. Joint surface preparation then consisted of curettage of the articular surfaces followed by reciprocal planing. Fenestration with a 2.0-mm drill bit and fish scaling with an osteotome was then performed at the fusion site. Intraoperative fluoroscopy was utilized to confirm alignment and position. The first metatarsal was plantarly translated on the medial cuneiform and fixation at the fusion site achieved via a 3.5-mm headless compression screw from distal dorsal to plantar proximal and a 4.0-mm cannulated screw from dorsal proximal to distal plantar. Both screws were noted to purchase well with excellent stability at the fusion site. Intraoperative fluoroscopy was utilized to confirm hardware placement and alignment. Attention was then directed to the first metatarsophalangeal joint where a dorsolinear capsular incision was made with periosteal incision extending along the course of the proximal phalanx. Inspection of the joint surface revealed a moderate amount of hemorrhagic synovitis within the joint. This was debrided. Articular cartilage was intact. There was no significant dorsal or medial prominence of the first metatarsal head. Abduction deformity at the hallux IP joint was present, which was found to be structural within the proximal phalanx. An oblique distal medially-based wedge osteotomy was then performed in the hallux proximal phalanx. This was fixated with a 3.0-mm headless compression screw. The screw was noted to purchase well. Excellent position and alignment were noted following the osteotomy. Good range of motion at the first MTP joint was evident as well. Attention was then directed to the dorsal aspect of the second digit where a linear incision was made centered over the PIP joint. Dissection was continued down to the level of the extensor tendon. A transverse tenotomy and capsulotomy was performed at the level of the PIP joint and capsular structures were freed from the head of the proximal phalanx and the base of the intermediate phalanx. The distal third of the head of the proximal phalanx was then sharply resected followed by curettage of the base of the intermediate phalanx. Fixation was achieved via 0.062-inch K-wire driven through the intermediate and distal phalanges and out the end of the toe and then retrograde driven down the shaft of the proximal phalanx. Intraoperative fluoroscopy was utilized to confirm apposition of the fusion site, position and alignment. Attention was then directed to the third digit where an identical procedure was performed. A copious lavage was then performed followed by closure of the capsular structures. The tourniquet was then deflated and prompt vascular return was noted to the foot and leg. Adequate hemostasis was obtained prior to layered closure of the wounds. Following wound closure, an Orthofix MiniRail external fixation device was utilized across the medial aspect of the foot spanning the fusion site at the first metatarsocuneiform joint. Two pins were placed in the medial cuneiform and two in the first metatarsal. Intraoperative fluoroscopy was utilized to confirm pin placement and fixator alignment. Postoperatively, an injection of 9 cc of 0.5% Marcaine plain and 1 cc of dexamethasone phosphate was performed around the surgery sites. A dry sterile compressive dressing was applied followed by a modified Jones compression splint with a posterior fiberglass shell and a Biogel Cryo/Cuff. The patient was then awakened from anesthesia.
The patient tolerated the procedures and the anesthesia well and was transferred to the recovery room with stable vital signs and neurovascular status intact. After a brief period of postoperative monitoring, he will be discharged home. He has written and verbal postoperative instructions, prescriptions for pain medication, crutches and instructions for strict nonweightbearing on the left lower extremity, and instructions to follow up with me in five days.


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