Case -AUDIT REPORT T7.2 OPERATIVE REPORT, SPLENECTOMY

Essay

Case
-AUDIT REPORT T7.2 OPERATIVE REPORT, SPLENECTOMY
LOCATION: Inpatient, Hospital
PATIENT: Marie Hill
SURGEON: Gary Sanchez, MD
PREOPERATIVE DIAGNOSIS: Intra-abdominal bleeding; ruptured spleen
POSTOPERATIVE DIAGNOSIS: Intra-abdominal bleeding; ruptured spleen
PROCEDURE PERFORMED: Splenectomy, total
ANESTHESIA: General anesthesia
INDICATION: Patient is a 24-year-old female involved in a one-car accident in which she lost control of her vehicle and went down a ditch and the vehicle rolled twice, landing in an upright position. Patient was only person in the vehicle and was restrained.
Patient has been conscious since paramedics arrived. Tests revealed bleeding in the abdomen. The spleen was suspected.
PROCEDURE: The patient was brought emergently to the operating room and placed under general anesthesia. She was prepped and draped while in the supine position. A left-sided Kocher incision was made.We used the Omni retractor and were able to look way into the abdomen. All of the organs looked intact and clear.We then identified a lot of bleeding in the area of the spleen, and a tear was noted. Under deeper inspection on the backside of the spleen a large tear was present, and decision was made to remove it. We lifted up on the spleen and brought it through the wound. The major vessels were divided. The short gastric vessels were dealt with in the same way. The spleen was then removed in its entirety. The areas were doubly tied, and care was taken to ligate and suture all the major vessels. Bleeding was controlled. We then irrigated and suctioned out the abdominal cavity and closed the wound with #2 Vicryl stitches in a two-layer fashion. We then irrigated out the wound and put in some staples. Marcaine 1.25% was placed in the wound. Telfa, toppers, and gauze were applied. The patient came through the surgery well and went on to the recovery room in good condition.
T7.2:
SERVICE CODE(S): 38115___________________________________________
ICD-10-CM DX CODE(S): S36.09XA___________________________________
INCORRECT/MISSING CODE(S): ____________________________________