Operative Report

Want create site? With you can do it easy.

Operative Report

Operative Report


Don't use plagiarized sources. Get Your Custom Essay on
Operative Report
Just from $13/Page
Order Essay

M132 Module 08 Coding Assignment

Build the correct ICD 10 PCS code based on the documentation in the Operative Report documentation given under each Case Study.

1. Case #1


1. A 37 weeks intrauterine pregnancy.

2. Previous cesarean section with rupture of membranes.


1. A 37 plus weeks gestation.

2. Previous cesarean section with spontaneous rupture of membranes.

3. Pelvic adhesions.


PROCEDURE PERFORMED: Repeat low-transverse cesarean section.

FINDINGS: Male infant, 6 pounds, 5 ounces. Apgars 9 and 9.


The patient’s condition after surgery, the patient tolerated the procedure well.

PERTINENT HISTORY AND PHYSICAL: The patient is a 20-year-old black female, gravida 2, para 1-0-0-1, last normal menstrual period 08/02/2006, EDC 05/08/2007, 37-5/7th weeks gestation, she presented to L D with spontaneous rupture of membranes, history of previous cesarean section in 2009 for CPD.

PAST MEDICAL HISTORY: She denies allergies.

MEDICATIONS: She is on prenatal vitamins.

MEDICAL SURGICAL: She denies any significant history except for C-section in 2006.

SOCIAL HISTORY: She denies ethanol, tobacco, or drugs.


FAMILY HISTORY: Noncontributory.

PHYSICAL EXAMINATION: Vital Signs: Temperature, the patient is afebrile, pulse 94, respiratory rate 20, BP 97/50, fetal heart tone was 140 to 145. HEENT was within normal limits. Neck is supple. Chest: Cardiovascular, Sl and S2 regular without gallop or murmur. Lungs: Clear both fields. Breasts: No masses or tenderness. Abdomen: Gravid. Pelvic: Cervix was 50% effaced, 1 to 2 cm dilated, presenting part was vertex at -2 station, there was gross fluid, clear and Nitrazine was positive. The patient was therefore taken to the operating room for a repeat low-transverse cesarean section.

OPERATIONAL TECHNIQUE: The patient was brought to the operating room and under spinal anesthesia, was prepped and draped in the usual manner for a gynecologic abdominal operation. Through the old suprapubic Pfannenstiel skin incision, the abdominal cavity was entered into after much difficulty because of the pelvic abdominal adhesion. Following entry into the abdominal cavity, the bladder peritoneum was identified, reflected down. Following that, a midline low-transverse incision was made at the lower uterine segment with a knife and carried down into the uterine cavity without any difficulty. The incision was then extended to the level of the round ligament on both sides. Following which a male infant in vertex position was delivered with vacuum and handed over to the nursery staff in attendance. Birth weight was 6 pounds 5 ounces. Apgar was 9 and 9. Placenta was manually delivered. After remnants of the placental membranes have been removed from the uterine cavity, the uterine cavity was then closed with #1 chromic continuous interlocking suture. Hemostasis was verified and found to be adequate. The ovaries and tubes were inspected and found to be within normal limits. The abdominal cavity was copiously irrigated. The abdominal cavity was then closed in layers. The pyramidal muscle was closed with 2-0 interrupted suture, the fascia was closed with #1 Vicryl continuous suture in two halves and the skin was closed with staples. The patient tolerated the procedure well and left the operating room, awake, conscious, and in excellent condition.


ICD-10-PCS Code: Click here to enter text.

2. Case Study #2


Description: This is an 18-channel digital EEG recording done on this 79-year-old male with a chief complaint of altered mental status .This patient is also on insulin for diabetes.

There is diffuse slowing and disorganization in the background consisting of medium-voltage theta rhythm at 4-6 Hz seen from all head areas. There was faster activity at beta range from the anterior. Eye movements and muscle artifacts are noted. EKG artifacts at 76 per minute were noted. Hyperventilation and Photic stimulation were not completed.

Findings: This is a moderately abnormal record due to diffuse slowing and disorganization of the background, with the slowing being at theta range. There is indication of a moderate encephalopathic condition. Clinical correlation is required to rule out a structural lesion.

ICD-10-PCS Code: Click here to enter text.

3. Case #3



PROCEDURE PERFORMED: Insertion of extracorporeal membrane oxygenation circuit.


OPERATIVE INDICATIONS: The patient a 52-year-old African American male who previously had placement of a HeartMate II left ventricular assist device. The device seems to be nonfunctional at this time despite multiple pressor support. He has continued to develop cardiogenic shock and multisystem organ failure. ECMO circuit is indicated to help stabilize him prior to a planned device exchange.

OPERATIVE TECHNIQUE: The patient was placed on the OR table in the supine position. General anesthesia was induced. He was prepped and draped in the usual sterile fashion. A small transverse incision was made in the right groin and right femoral artery and vein isolated. A 10-mm Hemashield graft was then sewn end to side to the common femoral artery after administration of intravenous heparin. The Hemashield graft was then tunneled subcutaneously to

exit the skin in the upper thigh. A 29-French percutaneous venous cannula was then placed in the femoral vein without difficulty. The cannula was then attached to the ankle circuit and flow initiated. There was excellent flow with excess of 6 liters per minute. Transesophageal echo showed good cannula placed in the right atrium. There was significant coagulopathic bleeding from the femoral artery which took in excess of 2 hours to control with various hemostatic agents. Eventually, hemostasis was assured and the wound closed in layered closure of Vicryl and subcuticular stitch for skin. The patient was returned to the ICU in critical condition.

ICD-10-PCS Code: Click here to enter text.

4. Case Study #4

Report of Operation

Preoperative Diagnosis: Retained products of conception

Postoperative Diagnosis: Retained products of conception

Procedure: Suction and D and C

Estimated blood loss: 50 cc

Fluids: 150 cc LR

Urine Output: 10 cc clear

Anesthesia: Spinal

Specimens: Products of Conception

Complications: None

Condition: Stable to Recovery Room

Procedure: The patient was taken to the operating room where spinal anesthesia was found to be adequate. She was prepped and draped in the normal sterile fashion and placed in the dorsal supine position lithotomy. A bivalve speculum was placed in the vagina. The cervix was adequately visualized. The anterior cervix was grasped with a one-tooth tenaculum and uterus was gently pulled forward. The uterus was gently sounded to approximately 7 cm and dilated to 10 mm. A 10 mm suction curet was then gently advanced into the uterus. The suction device was attached and suction was started and suction dilation and curettage was performed gently without difficulties. Some products of conception were obtained through the suction canister. Three passes were done with the suction curet. Excellent hemostatsis was noted. The one-tooth tenaculum was removed from the anterior lip of the cervix. The patient was noted to be hemostatic. All instruments were removed. The patient tolerated the procedure well and was taken to the recovery room in stable condition.

ICD-10-PCS code: Click here to enter text.

Operative Report

Did you find apk for android? You can find new and apps.

What Will You Get?

We provide professional writing services to help you score straight A’s by submitting custom written assignments that mirror your guidelines.

Premium Quality

Get result-oriented writing and never worry about grades anymore. We follow the highest quality standards to make sure that you get perfect assignments.

Experienced Writers

Our writers have experience in dealing with papers of every educational level. You can surely rely on the expertise of our qualified professionals.

On-Time Delivery

Your deadline is our threshold for success and we take it very seriously. We make sure you receive your papers before your predefined time.

24/7 Customer Support

Someone from our customer support team is always here to respond to your questions. So, hit us up if you have got any ambiguity or concern.

Complete Confidentiality

Sit back and relax while we help you out with writing your papers. We have an ultimate policy for keeping your personal and order-related details a secret.

Authentic Sources

We assure you that your document will be thoroughly checked for plagiarism and grammatical errors as we use highly authentic and licit sources.

Moneyback Guarantee

Still reluctant about placing an order? Our 100% Moneyback Guarantee backs you up on rare occasions where you aren’t satisfied with the writing.

Order Tracking

You don’t have to wait for an update for hours; you can track the progress of your order any time you want. We share the status after each step.


Areas of Expertise

Although you can leverage our expertise for any writing task, we have a knack for creating flawless papers for the following document types.

Areas of Expertise

Although you can leverage our expertise for any writing task, we have a knack for creating flawless papers for the following document types.


Trusted Partner of 9650+ Students for Writing

From brainstorming your paper's outline to perfecting its grammar, we perform every step carefully to make your paper worthy of A grade.

Preferred Writer

Hire your preferred writer anytime. Simply specify if you want your preferred expert to write your paper and we’ll make that happen.

Grammar Check Report

Get an elaborate and authentic grammar check report with your work to have the grammar goodness sealed in your document.

One Page Summary

You can purchase this feature if you want our writers to sum up your paper in the form of a concise and well-articulated summary.

Plagiarism Report

You don’t have to worry about plagiarism anymore. Get a plagiarism report to certify the uniqueness of your work.

Free Features $66FREE

  • Most Qualified Writer $10FREE
  • Plagiarism Scan Report $10FREE
  • Unlimited Revisions $08FREE
  • Paper Formatting $05FREE
  • Cover Page $05FREE
  • Referencing & Bibliography $10FREE
  • Dedicated User Area $08FREE
  • 24/7 Order Tracking $05FREE
  • Periodic Email Alerts $05FREE

Our Services

Join us for the best experience while seeking writing assistance in your college life. A good grade is all you need to boost up your academic excellence and we are all about it.

  • On-time Delivery
  • 24/7 Order Tracking
  • Access to Authentic Sources
Academic Writing

We create perfect papers according to the guidelines.

Professional Editing

We seamlessly edit out errors from your papers.

Thorough Proofreading

We thoroughly read your final draft to identify errors.


Delegate Your Challenging Writing Tasks to Experienced Professionals

Work with ultimate peace of mind because we ensure that your academic work is our responsibility and your grades are a top concern for us!

Check Out Our Sample Work

Dedication. Quality. Commitment. Punctuality

It May Not Be Much, but It’s Honest Work!

Here is what we have achieved so far. These numbers are evidence that we go the extra mile to make your college journey successful.


Happy Clients


Words Written This Week


Ongoing Orders


Customer Satisfaction Rate

Process as Fine as Brewed Coffee

We have the most intuitive and minimalistic process so that you can easily place an order. Just follow a few steps to unlock success.

See How We Helped 9000+ Students Achieve Success


We Analyze Your Problem and Offer Customized Writing

We understand your guidelines first before delivering any writing service. You can discuss your writing needs and we will have them evaluated by our dedicated team.

  • Clear elicitation of your requirements.
  • Customized writing as per your needs.

We Mirror Your Guidelines to Deliver Quality Services

We write your papers in a standardized way. We complete your work in such a way that it turns out to be a perfect description of your guidelines.

  • Proactive analysis of your writing.
  • Active communication to understand requirements.

We Handle Your Writing Tasks to Ensure Excellent Grades

We promise you excellent grades and academic excellence that you always longed for. Our writers stay in touch with you via email.

  • Thorough research and analysis for every order.
  • Deliverance of reliable writing service to improve your grades.
Place an Order Start Chat Now