Basic Civil Engineering notes on Transportation Engineering & Modes of Transport
Audit report Operative.pdf
1. Audit report 10.6 Operative report, cystoscopy...
Audit report 10.6 Operative report, cystoscopy
LOCATION: Outpatient, Hospital
PATIENT: Eileen Lab
SURGEON: Ira Avila, MD
PREOPERATIVE DIAGNOSIS: Left ureteral calculus
POSTOPERATIVE DIAGNOSIS: Left ureteral calculus
PROCEDURE PERFORMED: Cystoscopy, bilateral retrograde pyelograms, left ureteroscopy,
stone extraction.
PROCEDURE: The patient was given a general laryngeal mask anesthetic, prepped, and
draped in the lithotomy position. The patient was cystoscoped using a 21-French
instrument. There was no evidence of urethral or bladder abnormality. Bilateral retrograde
pyelograms were performed that showed normal collecting system of the right-hand side.
There was only a minimal suggestion of a filling defect in the distal ureter on the left. There
was minimal dilation of the left collecting system, and clear urine could be seen effluxing
from both orifices. Because her symptoms were so classic for a stone, I decided to
ureteroscope the patient anyway. A stiff Terumo guidewire was advanced up the ureter
under fluoroscopic control and then followed this with a 7-French rigid short ureteroscope
without prior ureteral dilation. Just at the level of Waldeyer's fascia, a stone was visualized.
This was entrapped in a helical basket and withdrawn under visual guidance. Repeat
ureteral inspection showed no evidence of abrasion or edema; therefore, it was decided not
to stent the patient. The bladder was drained and cystoscope withdrawn. B&O suppository
was placed rectally. She tolerated the procedure well and was transferred to the recovery
room in good condition. She will be discharged later today. Follow-up will be arranged for
ultrasound in 3 months' time.
One or more of the following codes are reported incorrectly for this case. Indicate the
incorrect code or codes.
SERVICE CODE(S): Cystourethroscopy with FB removal, 52310; Cystourethroscopy,
52000-51
ICD-10-CM DX CODE(S): Kidney stone, N20.0
INCORRECT/MISSING CODE(S): ___________________________________
