Case -T12-2C OPERATIVE REPORT, SUBDURAL HEMATOMA This Is Not the Same

Essay

Case
-T12-2C OPERATIVE REPORT, SUBDURAL HEMATOMA This is not the same patient as in T12-2B.
LOCATION: Inpatient, Hospital
PATIENT: Robert Vobr
ATTENDING PHYSICIAN: Ronald Green, MD
SURGEON: Timothy Pleasant, MD
PREOPERATIVE DIAGNOSIS: Subdural hematoma, traumatic
POSTOPERATIVE DIAGNOSIS: Subdural hygroma, traumatic
ANESTHESIA: Local; standby
PROCEDURE: The patient's head was prepped and draped in the usual manner. An incision was made in the frontal left and left posterior parietal area. The skin was incised. Retractor was placed. Bone was isolated. Perforator was utilized. Burr hole was made, and the dura was incised and coagulated. Clear CSF (cerebrospinal fluid) exuded. This was a subdural hygroma. The brain was deep to the subdural hygroma. We placed two Penrose drains and then closed the wounds with 2-0 Vicryl on the galea with surgical staples on the skin. Dressing was applied. The patient was discharged to recovery.
T12-2C:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________