OUTPATIENT ICD-9 AND ICD-10-CM CODING

Medical Specialty: Endocrinology

Acquired hypothyroidism

Description:

Return visit to the endocrine clinic for acquired hypothyroidism, papillary carcinoma of the thyroid gland status post total thyroidectomy in 1992, and diabetes mellitus.

PROBLEM LIST:

  • Acquired hypothyroidism.
  • Papillary carcinoma of the thyroid gland, status post total thyroidectomy in 1992.
  • Diabetes mellitus.
  • Insomnia with sleep apnea.

HISTORY OF PRESENT ILLNESS:

This is a return visit to the endocrine clinic for the patient with history as noted above. She is 45 years old. Her last visit was about 6 months ago. Since that time, the patient states her health has remained unchanged. Currently, primary complaint is one of fatigue that she feels throughout the day. She states, however, she is doing well with CPAP and wakes up feeling refreshed but tends to tire out later in the day. In terms of her thyroid issues, the patient states that she is not having signs or symptoms of thyroid excess or hypothyroidism. She is not reporting temperature intolerance, palpitations, muscle weakness, tremors, nausea, vomiting, constipation, hyperdefecation or diarrhea. Her weight has been stable. She is not reporting proximal muscle weakness.

CURRENT MEDICATIONS:

  • Levothyroxine 125 micrograms p.o. once daily.
  • CPAP.
  • Glucotrol.
  • Avandamet.
  • Synthroid.
  • Byetta injected twice daily.

REVIEW OF SYSTEMS:

As stated in the HPI. She is not reporting polyuria, polydipsia or polyphagia. She is not reporting fevers, chills, sweats, visual acuity changes, nausea, vomiting, constipation or diarrhea. She is not having any lightheadedness, weakness, chest pain, shortness of breath, difficulty breathing, orthopnea or dyspnea on exertion.

PHYSICAL EXAMINATION:

GENERAL:

She is an overweight, very pleasant woman, in no acute distress. VITAL SIGNS: Temperature 96.9, pulse 85, respirations not counted, blood pressure 135/65, and weight 85.7 kg. NECK: Reveals well healed surgical scar in the anteroinferior aspect of the neck. There is no palpable thyroid tissue noted on this examination today. There is no lymphadenopathy. THORAX: Reveals lungs that are clear, PA and lateral, without adventitious sounds. CARDIOVASCULAR: Demonstrated regular rate and rhythm. S1 and S2 without murmur. No S3, no S4 is auscultated. EXTREMITIES: Deep tendon reflexes 2+/4 without a delayed relaxation phase. No fine resting tremor of the outstretched upper extremity. SKIN, HAIR, AND NAILS: All are unremarkable.

LABORATORY DATABASE:

Lab data on 08/29/07 showed the following: Thyroglobulin quantitative less than 0.5 and thyroglobulin antibody less than 20, free T4 1.35, and TSH suppressed at 0.121.

ASSESSMENT AND PLAN:

This is a 45 year-old woman with history as noted above.

  • Acquired hypothyroidism, status post total thyroidectomy for papillary carcinoma in 1992.
  • Plan to continue following thyroglobulin levels.
  • Plan to obtain a free T4, TSH, and thyroglobulin levels today.
  • Have the patient call the clinic next week for followup and continued management of her hypothyroid state.
  • Plan today is to repeat her thyroid function studies. This case was discussed with Dr. X and the recommendation. We are giving the patient today is for us to taper her medication to get her TSH somewhere between 0.41 or less. Therefore, labs have been drawn. We plan to see the patient back in approximately 6 months or sooner. A repeat body scan will not been done, the one in 03/06 was negative.
  • 244.0, 250.00, 780.51; E89.0, E11.9, G47.30, G47.00
  • 244.1, 250.01, 780.50; E89.0, E10.9, G47.9
  • 244.8, 249.91, 780.52; E03.8, E08.0, G47.00
  • 244.0, 250.93, 780.57; E89.0, E10.8, G47.30, G47.00

Answer

Acute cystitis and diabetes mellitus type 2

Description:

The patient complaining of abdominal pain, has a long-standing history of diabetes treated with Micronase daily.

HISTORY OF PRESENT ILLNESS:

The patient is a 45 year-old male complaining of abdominal pain. The patient also has a long-standing history of diabetes which is treated with Micronase daily.

PAST MEDICAL HISTORY:

There is no significant past medical history noted today.

PHYSICAL EXAMINATION:

HEENT:

Patient denies ear abnormalities, nose abnormalities and throat abnormalities.

Cardio:

Patient has history of elevated cholesterol, but does not have ASHD, hypertension and PVD.

Resp:

Patient denies asthma, lung infections and lung lesions.

GI:

Patient denies colon abnormalities, gall bladder problems, liver abnormalities and peptic ulcer disease.

GU:

Patient has history of Urinary tract disorder, but does not have Bladder disorder and Kidney disorder.

Endocrine:

Patient has history of diabetes, but does not have hormonal irregularities and thyroid abnormalities.

Dermatology:

Patient denies allergic reactions, rashes and skin lesions.

MEDS:

Micronase 2.5 mg Tab PO QAM #30. Bactrim 400/80 Tab PO BID #30.

SOCIAL HISTORY:

No known history of drug or alcohol abuse. Work, diet, and exercise patterns are within normal limits.

FAMILY HISTORY:

No significant family history.

REVIEW OF SYSTEMS:

Non-contributory.

Vital Signs:

Height = 72 in. Weight =184 lbs. Upright BP = 120/80 mmHg. Pulse = 80 bpm. Resp =12 pm. Patient is afebrile.

Neck:

The neck is supple. There is no jugular venous distension. The thyroid is nontender, or normal size and contour.

Lungs:

Lung expansion and excursions are symmetric. The lungs are clear to auscultation and percussion.

Cardio:

There is a regular rhythm. SI and S2 are normal. No abnormal heart sounds are detected. Blood pressure is equal bilaterally.

Abdomen:

Normal bowel sounds are present. The abdomen is soft; The abdomen is nontender; without organomegaly; There is no CVA tenderness. No hernias are noted.

Extremities:

There is no clubbing, cyanosis, or edema.

ASSESSMENT:

Diabetes type II uncontrolled. Acute cystitis.

PLAN:

Endocrinology Consult, complete CBC.

RX:

Micronase 2.5 mg Tab PO QAM #30, Bactrim 400/80 Tab PO BID #30.

  • 250.02, 594.2; E11.9, N21.0
  • 250.02, 595.0; E11.9, N30.00
  • 250.03, 599.0; E10.65, N39.0
  • 250.02, 595.4; E11.9, N30.80

Answer

Nontoxic multinodular goiter

SUBJECTIVE:

The patient is a 32 year-old male who returns for followup of thyroid problems. He has been doing fairly well otherwise.

OBJECTIVE:

Vitals are normal. The head is normocephalic. Nose is normal. Throat is clear. Teeth tongue and gums are normal. Neck is supple. The chest is normal shape and symmetrical with good expansion. The lungs are clear on auscultation. The heart has a regular rhythm; no murmurs. The abdomen is soft and nontender; no hepatosplenomegaly. The joints are normal. Peripheral pulsations are normal. Skin is normal. Extremities have no edema. Neurological – Cranials are intact. Motor and sensory are normal. Reflexes are normal.

ASSESSMENT:

Incidental finding of nodule in the left lobe of the thyroid on ultrasound; there are multiple solid small nodules. Nuclear scan is normal. Thyroglobulin level is normal. Microsomal antibodies are normal and so are the thyroid lab tests.

At this time the patient is not symptomatic. There is no cervical lymphadenopathy.

I discussed the case with the family; he came in with his wife. They seem to understand the plan very well. An order for an ultrasound in 6 months is requested.

PLAN:

  • Observe and repeat the ultrasound in 6 months.
  • A followup visit after the ultrasound.
  • The patient is to be seen and followed.
  • 240.0; E04.0
  • 240.9; E04.9
  • 241.1; E04.2
  • 242.00; E05.00

Answer

Adrenal and pancreatic lesions

Description:

Left adrenal and pancreatic lesions. The adrenal lesion is a small lesion, appears as if probable benign adenoma, whereas the pancreatic lesion is a cystic lesion, and neoplasm could not be excluded.

CHIEF COMPLAINT:

Both left adrenal lesions and pancreatic.

HISTORY OF PRESENT ILLNESS:

This 60 year-old white male is referred to us by his medical physician with a complaint of recent finding of a both pancreatic lesion and lesions with left adrenal gland. The patient's history dates back to at the end of the January of this past year when he began experiencing symptoms consistent with difficulty almost like a suffocating feeling whenever he would lie flat on his back. He noticed whenever he would recline backwards, he would begin this feeling and it is so bad now that he can barely recline, very little before he has this feeling. He is now sleeping in an upright position. He was sent for CAT scan originally of his chest. The CAT scan of the chest reveals a pneumonitis, but also saw a left adrenal nodule and a small pancreatic lesion. He was subsequently was sent for a dedicated abdominal CAT scan and MRI. The CAT scan revealed 1.8-cm lesion of his left adrenal gland, suspected to be a benign adenoma. The pancreas showed pancreatic lesion towards the mid body tail aspect of the pancreas, approximately 1 cm, most likely of cystic nature. Neoplasm could not be excluded. He was referred to us for further assessment. He denies any significant abdominal pain, any nausea or vomiting. His appetite is fine. He has had no significant changes in his bowel habits or any rectal bleeding or melena. He has undergone a colonoscopy in September of last year and was found to have three adenomatous polyps. He does have a history of frequent urination. Has been followed by urologist for this. There is no family history of pancreatic cancer. There is a history of gallstone pancreatitis in the patient's sister.

PAST MEDICAL HISTORY:

Significant for hypertension, type 2 diabetes mellitus, asthma, and high cholesterol.

ALLERGIES:

ENVIRONMENTAL.

MEDICATIONS:

Include glipizide 5 mg b.i.d., metformin 500 mg b.i.d., Atacand 16 mg daily, metoprolol 25 mg b.i.d., Lipitor 10 mg daily, pantoprazole 40 mg daily, Flomax 0.4 mg daily, Detrol 4 mg daily, Zyrtec 10 mg daily, Advair Diskus 100/50 mcg one puff b.i.d., and fluticasone spray 50 mcg two sprays daily.

PAST SURGICAL HISTORY:

He has not had any previous surgery.

FAMILY HISTORY:

His brothers had prostate cancer. Father had brain cancer. Heart disease in both sides of the family. Has diabetes in his brother and sister.

SOCIAL HISTORY:

He is a non-cigarette smoker and non-ETOH user. He is single and he has no children. He works as a payroll representative and previously did lot of work in jewelry business, working he states with chemical.

REVIEW OF SYSTEMS:

He denies any chest pain. He admits to exertional shortness of breath. He denies any GI problems as noted. Has frequent urination as noted. He denies any bleeding disorders or bleeding history.

PHYSICAL EXAMINATION:

GENERAL:

Presents as an obese 60 year-old white male, who appears to be in no apparent distress.

HEENT:

Unremarkable.

NECK:

Supple. There is no mass, adenopathy or bruit.

CHEST:

Normal excursion.

LUNGS:

Clear to auscultation and percussion.

COR:

Regular. There is no S3 or S4 gallop. There is no obvious murmur.

HEART:

There is distant heart sounds.

ABDOMEN:

Obese. It is soft. It is nontender. Examination was done as relatively sitting up as the patient was unable to recline. Bowel sounds are present. There is no obvious mass or organomegaly.

GENITALIA:

Deferred.

RECTAL:

Deferred.

EXTREMITIES:

Revealed about 1+ pitting edema. Bilateral peripheral pulses are intact.

NEUROLOGIC:

Without focal deficits. The patient is alert and oriented.

IMPRESSION:

Both left adrenal and pancreatic lesions. The adrenal lesion is a small lesion, suspected to be a benign adenoma. The pancreas showed pancreatic lesion towards the mid body tail aspect of the pancreas, approximately 1 cm, most likely of cystic nature. Neoplasm could not be excluded. Given the location of these pancreatic lesions in the mid body towards the tail and size of 1 cm, the likelihood is an ERCP will be of no value and the likelihood is that it is too small to biopsy. We are going to review x-rays with Radiology prior with the patient probably at some point will present for operative intervention. Prior to that the patient will undergo an esophagogastroduodenoscopy.

  • 227.1, 577.9; D35.1, K86.9
  • 227.0, 577.1; D35.00, K86.1
  • 227.8, 577.0; D35.7, K85.9
  • 227.0, 577.2; D35.02, K86.2

Answer

Papillary carcinoma of thyroid - Completion hemithyroidectomy

Description:

The patient with of the left parathyroid and left sternocleidomastoid region in the inferior 1/3rd region. Papillary carcinoma of the follicular variant of the thyroid in the right lobe, status post right hemithyroidectomy.

PREOPERATIVE DIAGNOSES:

Papillary carcinoma of the follicular variant of the thyroid in the right lobe, status post right hemithyroidectomy.

POSTOPERATIVE DIAGNOSES:

Papillary carcinoma of the follicular variant of the thyroid in the right lobe, status post right hemithyroidectomy.

PROCEDURE:

The patient with left completion hemithyroidectomy and reimplantation of the left parathyroid and left sternocleidomastoid region in the inferior 1/3rd region.

FINDINGS:

Normal-appearing thyroid gland with a possible lump in the inferior aspect, there was a parathyroid gland that by frozen section _________ was not thyroid, it was reimplanted to the left lower sternocleidomastoid region.

ESTIMATED BLOOD LOSS:

Approximately 10 mL.

FLUIDS:

Crystalloid only.

COMPLICATIONS:

None.

DRAINS:

Rubber band drain in the neck.

CONDITION:

Stable.

PROCEDURE:

The patient placed supine under general anesthesia. First, a shoulder roll was placed, 1% lidocaine and 1:100,000 epinephrine was injected into the old scar, natural skin fold, and Betadine prep. Sterile dressing was placed. The laryngeal monitoring was noted to be working fine. Then, an incision was made in this area in a curvilinear fashion through the old scar, taken through the fat and the platysma level. The strap muscles were found and there was scar tissue along the trachea and the strap muscles were elevated off of the left thyroid, the thyroid gland was then found. Then, using bipolar cautery and a Coblation dissector, the thyroid gland inferiorly was dissected off and the parathyroid gland was left inferiorly and there was scar tissue that was released and laterally, the thyroid gland was released, then came into the Berry ligaments. The Berry ligament was dissected off and the gland came off all the way to the superior and inferior thyroid vessels, which were crossed with the Harmonic scalpel and removed. No bleeding was seen. There was a small nick in the external jugular vein that was tied with a 4-0 Vicryl suture ligature. After this was completed, on examining the specimen, there appeared to be a lobule on it and it was sent off as possibly parathyroid, therefore it was reimplanted in the left lower sternocleidomastoid region using the silk suture ligature. After this was completed, no bleeding was seen. The laryngeal nerve could be seen and intact and then Rubber band drain was placed throughout the neck along the thyroid bed and 4-0 Vicryl was used to close the strap muscles in an interrupted fashion along with the platysma region and subcutaneous region and a running 5-0 nylon was used to close the skin and Mastisol and Steri-Strips were placed along the skin edges and then on awakening, both laryngeal nerves were working normally. Procedure was then terminated at that time.

  • 194.1; C75; 60240, 60512
  • 194.9; C75.9; 60220, 60512
  • 193; C73; 60260, 60512
  • 194.8; C75.8; 60210, 60512

Answer

Diabetes mellitus type 1

Description:

Return visit to the endocrine clinic for followup management of type 1 diabetes mellitus. Plan today is to make adjustments to her pump based on a total daily dose of 90 units of insulin.

PROBLEM LIST:

  • Type 1 diabetes mellitus, insulin pump.
  • Hypertension.
  • Hyperlipidemia.

HISTORY OF PRESENT ILLNESS:

The patient is a 39 year-old woman returns for followup management of type 1 diabetes mellitus. Her last visit was approximately 4 months ago. Since that time, the patient states her health had been good and her glycemic control had been good, however, within the past 2 weeks she had a pump malfunction, had to get a new pump and was not certain of her pump settings and has been having some difficulty with glycemic control over the past 2 weeks. She is not reporting any severe hypoglycemic events, but is having some difficulty with hyperglycemia both fasting and postprandial. She is not reporting polyuria, polydipsia or polyphagia. She is not exercising at this point and has a diet that is rather typical of woman with twins and a young single child as well. She is working on a full-time basis and so eats on the run a lot, probably eats more than she should and not making the best choices, little time for physical activity. She is keeping up with all her other appointments and has recently had a good eye examination. She had lab work done at her previous visit and this revealed persistent hyperlipidemic state with a LDL of 144.

CURRENT MEDICATIONS:

  • Zoloft 50 mg p.o. once daily.
  • Lisinopril 40 mg once daily.
  • Symlin 60 micrograms, not taking at this point.
  • Folic acid 2 by mouth every day.
  • NovoLog insulin via insulin pump about 90 units of insulin per day.

REVIEW OF SYSTEMS:

She denies fever, chills, sweats, nausea, vomiting, diarrhea, constipation, abdominal pain, chest pain, shortness of breath, difficulty breathing, dyspnea on exertion or change in exercise tolerance. She is not having painful urination or blood in the urine. She is not reporting polyuria, polydipsia or polyphagia.

PHYSICAL EXAMINATION:

GENERAL:

Today showed a very pleasant, well-nourished woman, in no acute distress.

VITAL SIGNS:

Temperature not taken, pulse 98, respirations 20, blood pressure 148/89, and weight 91.19 kg.

THORAX:

Revealed lungs clear, PA and lateral without adventitious sounds.

CARDIOVASCULAR:

Demonstrated regular rate and rhythm. S1 and S2 without murmur. No S3, no S4 auscultated.

ABDOMEN:

Nontender.

EXTREMITIES:

Showed no clubbing, cyanosis or edema.

SKIN:

Intact and do not appear atrophic. Deep tendon reflexes were 2+/4 without a delayed relaxation phase.

LABORATORY DATA:

Dated 10/05/08 showed a total cholesterol of 223, triglyceride 140, HDL 54, and LDL 144. The hemoglobin A1c was 6.4 and the spot urine for microalbumin was 9.2 micrograms of protein, 1 mg of creatinine. Sodium 136, potassium 4.5, chloride 102, CO2 30 mEq, BUN 11 mg/dL, creatinine 0.6 mg, estimated GFR greater than 60, blood sugar 118, calcium 9.4, and her LFTs were unremarkable. TSH is 1.07 and free T4 is 0.81.

ASSESSMENT AND PLAN:

  • This is a return visit to the endocrine clinic for the patient, a 39 year-old woman with history as noted above. Plan today is to make adjustments to her pump based on a total daily dose of 90 units of insulin. Basal rate is as follows, 12 a.m. 1.5, 02:30 a.m. 1.75, and 6 a.m. 1.5. Her correction factor is 19. Her carb/insulin ratio is 6. Her active insulin time is 5 and her targets are at 12 a.m. 110 and 6 a.m. to midnight is 100. We made adjustments to her pump and the plan will be to see her back in approximately 2 months.
  • Hyperlipidemia. The patient is not taking statin, therefore, we will prescribe Lipitor 20 mg one p.o. once daily. Have her watch for side effects from the medication and plan to do a fasting lipid panel and CMP approximately 8 weeks from now.
  • We will get a hemoglobin A1c and spot urine for albumin in 8 weeks as well.
  • 250.00, 401.1, 271.9, V46.8; E11.9, I10, E74.9, Z99.89
  • 250.01, 401.9, 272.4, V65.46; E10.9, I10, E78.5, Z46.81
  • 249.80, 796.2, 272.6, V45.85; E13.69, R03.0, E88.1, Z96.41
  • 250.00, 796.4, 272.4, V46.9; E10.9, R68.89, E78.4, Z99.89

Answer

Diabetes mellitus type 1

Description:

Followup diabetes mellitus, type 1.

CHIEF COMPLAINT:

Followup diabetes mellitus, type 1.

SUBJECTIVE:

Patient is a 34 year-old male with significant diabetic neuropathy. He has been off on insurance for over a year. Has been using NPH and Regular insulin to maintain his blood sugars. States that he is deathly afraid of having a low blood sugar due to motor vehicle accident he was in several years ago. Reports that his blood sugar dropped too low which caused the accident. Since this point in time, he has been unwilling to let his blood sugars fall within a normal range, for fear of hypoglycemia. Also reports that he regulates his blood sugars with how he feels, rarely checking his blood sugar with a glucometer.

Reports that he has been worked up extensively at hospital and was seeing an Endocrinologist at one time. Reports that he had some indications of kidney damage when first diagnosed. His urine microalbumin today is 100. His last hemoglobin A1C drawn at the end of December is 11.9. Reports that at one point, he was on Lantus which worked well and he did not worry about his blood sugars dropping too low. While using Lantus, he was able to get his hemoglobin A1C down to 7. His last CMP shows an elevated alkaline phosphatase level of 168. He denies alcohol or drug use and is a non smoker. Reports he quit drinking 3 years ago. I have discussed with patient that it would be appropriate to do an SGGT and hepatic panel today. Patient also has GERD and a history of impotence. Patient requests Nexium and Viagra, neither of which are covered under the Health Plan.

PHYSICAL EXAMINATION:

WD, WN. Slender, 34 year-old white male. VITAL SIGNS: Blood sugar 145, blood pressure 120/88, heart rate 104, respirations 16. Microalbumin 100. SKIN: There appears to be 2 skin lacerations on the left parietal region of the scalp, each approximately 1 inch long. No signs of infection. Wound is closed with new granulation tissue. Appears to be healing well. HEENT: Normocephalic. PERRLA. EOMI. TMs pearly gray with landmarks present. Nares patent. Throat with no redness or swelling. Nontender sinuses. NECK: Supple. Full ROM. No LAD. CARDIAC: RRR. No murmurs, rubs, or gallops. RESPIRATORY: CTA. ABDOMEN: Soft, nontender. No HSM and no masses. NEURO: Significant for lower extremity numbness throughout. Microfilament test shows more than 3 regions without sensation bilaterally. Bottoms of feet appear calloused and dry. Skin is intact. Cranial nerves 2-12 grossly nonfocal. Cerebellar function intact demonstrated through RAM.

ASSESSMENT:

  • 1. Diabetes mellitus, type 1, poorly controlled.
  • 2. Significant diabetic neuropathy with positive microalbuminuria.
  • 3. Elevated Alk Phos, etiology unclear.

PLAN:

  • 1. Diabetes mellitus type 1: We will follow up the elevated alkaline phosphatase with an SGGT and a hepatic function panel. The positive microalbumin is 100 today. He will be placed on a low dose Ace Inhibitor. I will put in a Prior Authorization for Lantus. I have also asked the patient to keep a log of his blood sugars for 2 weeks. Patient agrees to this. We may need to put in a referral to Endocrinology to get him stabilized. Prescription given for Prilosec OTC for GERD symptoms.
  • 250.60, 790.95, 530.5; E11.40, R79.82, K22.4
  • 250.61, 790.99, 530.6; E10.40, R78.89, K22.5
  • 250.63, 790.8, 790.6, 530.9; E10.40, B34.9, R79.0, K22.9
  • 250.61, 791.0, 790.5, 530.81; E10.40, R80.9, R74.8, K21.9

Answer

Diabetes mellitus type 2

Description:

Followup on diabetes mellitus type 2.

CHIEF COMPLAINT:

Followup on diabetes mellitus, hypercholesterolemia, and sinusitis.

SUBJECTIVE:

A 70 year-old female who was diagnosed with diabetes mellitus last fall. She has been checking her Accu-Cheks generally once a day, and they range from 82 to a high of 132. She feels well. She walks 1-2 miles most days. If the weather is bad, they go to a local mall. Otherwise they walk outside. She does complain of some sinus congestion and drainage for the last several weeks. She is up-to-date on her mammogram that she had at the Baylis Building. She sees Dr. Cheng for her gynecological care. She is a nonsmoker. Denies abdominal pain, nausea, vomiting, diarrhea, constipation, blood in her urine, blood in her stools. She has nocturia x 1. Denies swelling in her ankles. She checks her feet regularly.

PAST MEDICAL HISTORY:

Refer to chart.

MEDICATIONS:

Refer to chart.

ALLERGIES:

Refer to chart.

PHYSICAL EXAMINATION:

Vitals:

Wt: 185 B/P: 142/70. When she checks it at the mall and other places, it is usually about 120/56. T: 96.5 P: 84 and regular.

General:

A 70 year-old female who does not appear to be in acute distress.

HEENT:

She has frontal and maxillary sinus tenderness on the right to palpation. The right TM is slightly dull.

Neck:

Supple.

Heart:

Clear.

Lungs:

Clear.

Abdomen:

Large, nontender. No swelling.

IMPRESSION:

  • Diabetes mellitus.
  • Sinusitis.
  • Hypercholesterolemia

PLAN:

  • Allegra D 1 p.o. b.i.d. x 3 days.
  • Allegra 180 mg daily x 7 days.
  • Check an A1c, BMP, lipid profile, TSH.
  • She was given a copy of Partners in Prevention.
  • We discussed colonoscopy, and she is not ready to do that right now.
  • Will check stools for occult blood x 3. She is aware that a colonoscopy could pick up an early cancer.
  • Diet, exercise, weight loss stressed. We will let her know the results of her tests.
  • Refilled her prescriptions x 6 months.
  • 250.00, 473.8, 272.4; E11.9, J32.4, E78.4
  • 250.01, 472.1, 272.2; E10.9, J31.2, E78.2
  • 250.02, 473.8, 272.4; E11.65, J32.8, E78.5
  • 250.00, 473.9, 272.0; E11.9, J32.9, E78.0

Answer

Left thyroid mass - Total thyroid lumpectomy

Description:

Total Thyroid Lumpectomy

PREOPERATIVE DIAGNOSIS:

Left thyroid mass.

POSTOPERATIVE DIAGNOSIS:

Left thyroid mass.

PROCEDURE PERFORMED:

Left total thyroid lumpectomy.

ANESTHESIA:

General endotracheal.

ESTIMATED BLOOD LOSS:

Less than 50 cc.

COMPLICATIONS:

None.

INDICATIONS FOR PROCEDURE:

The patient is a 76 year-old Caucasian female with a history of a left thyroid mass nodule that was confirmed with CT scan along with thyroid uptake scan, which demonstrated a hot nodule on the left anterior pole. The patient was then discussed the risks, complications, and consequences of a surgical procedure and a written consent was obtained.

PROCEDURE:

The patient is brought to the operative suite by Anesthesia. The patient was placed on the operative table in supine position. After this, the patient was placed under general endotracheal intubation anesthesia and the patient was then placed upon a shoulder roll. After this, the skin incision was marked approximately two fingerbreadths above the sternal notch. It was then localized with 1% lidocaine with epinephrine 1:1000 approximately 7 cc total.

After this, the patient was then prepped and draped in the usual sterile fashion and a #10 blade was then utilized to make a skin incision. The subcutaneous tissue was then bluntly dissected utilizing a Ray-Tec sponge and a bear claw was then utilized to retract the upper incisional skin with counter retraction performed to allow a subplatysmal plane of skin flaps to be performed in superior and inferolateral directions. After this, the midline was then identified and grasped on either side with a DeBakey forceps. The raphe was noted and Bovie cauterization was utilized to cut down into this region. The fine stats were utilized to further open this area with exposure and bisection of the sternothyroid muscle. It was separated on the left side from the patient's sternothyroid muscle. After this, the sternothyroid muscle was identified, grasped with the DeBakey forceps and infiltrated initially through its fascial plane with the Metzenbaum scissors. Blunt dissection was then utilized to free the sternothyroid muscle from the thyroid gland in superior and inferior directions and laterally with the help of Kitners. After this, the plane was rotated more anteriorly with the superior and inferior parathyroid glands identified. The fat cap was noted to be attached on the superior parathyroid to the posterior aspect of the thyroid itself. It was freed from the thyroid gland and reflected laterally and posteriorly. The inferior parathyroid gland actually appeared to be attached also to the inferior aspect of the thyroid itself and was reflected laterally. After this, the patient's thyroid gland was palpated noting a thyroid nodule in the posterior inferior aspect along with the calcification laterally. The nodule appeared to be sort of rubbery in consistency and approximately 1 cm diameter. As the gland was rotated more anteriorly, the recurrent laryngeal nerve on the left side was identified and further dissection along Berry's ligament on the medial aspect was performed. The middle thyroid vein and inferior thyroid artery were both cauterized with a bipolar cautery and bisected. After this, the gland was easily rotated anteriorly with further dissection carried up to the superior pole. The superior pole was exposed with the help of a Richardson and Army-Navy retractors with cross-clamping and tying of the superior laryngeal artery and vein. Further, the small bleeding vessels were identified and bipolared, and cut with the Metzenbaum scissors. The superior pole was finally freed and the gland was rotated more anteriorly onto the anterior aspect of the trachea. Berry's ligament was finally freed and the gland was cross-clamped on the opposing thyroid isthmus with a mosquito. After this, the gland was cut with a Metzenbaum scissors and tied with a #3-0 undyed Vicryl tie. The defect on the neck now was thoroughly irrigated with normal saline solution and further bleeding was controlled with bipolar cauterization. Surgicel was then cut in small strips and three replaced in the lateral part of the neck.

The opposing side of the thyroid gland on the right was palpated with no noticeable nodules or masses. The strap muscles were then reapproximated with #3-0 Vicryl on a SH, followed by reapproximation of the subcutaneous tissue with #4-0 Vicryl, followed by reapproximation of the skin by running subcuticular #5-0 Prolene and a #6-0 fast absorbing gut. Mastisol, Steri-Strips, and bacitracin were placed followed by a sterile 4 x 4 dressing. The patient was then turned back to Anesthesia, extubated in the operating room, and transferred to Recovery in stable condition. The patient tolerated the procedure well and will be admitted to hospital for 23-hour observation and will be followed up in one week afterwards.

  • 246.9; E07.9; 60200
  • 246.2; E04.1; 60220
  • 246.8; E03.4; 60210
  • 246.8; E07.89; 60252

Answer

Thyroid goiter - Total thyroidectomy

Description:

Total Thyroidectomy.

PREOPERATIVE DIAGNOSIS:

Thyroid goiter with substernal extension on the left.

POSTOPERATIVE DIAGNOSIS:

Thyroid goiter with substernal extension on the left.

PROCEDURE PERFORMED:

Total thyroidectomy with removal of substernal extension on the left.

THIRD ANESTHESIA:

General endotracheal.

ESTIMATED BLOOD LOSS:

Approximately 200 cc.

COMPLICATIONS:

None.

INDICATIONS FOR PROCEDURE:

The patient is a 54 year-old Caucasian male with a history of an enlarged thyroid gland who presented to the office initially with complaints of dysphagia and some difficulty in breathing while lying supine. The patient subsequently then had a CT scan which demonstrated a very large thyroid gland, especially on the left side with substernal extension down to the level of the aortic arch. The patient was then immediately set up for surgery. After risks, complications, consequences, and questions were addressed with the patient, a written consent was obtained.

PROCEDURE:

The patient was brought to the operative suite by Anesthesia and placed on the operative table in the supine position. The patient was then placed under general endotracheal intubation anesthesia and the patient then had a shoulder roll placed. After this, the patient then had the area marked initially. The preoperative setting was then localized with 1% lidocaine and epinephrine 1:100,000 approximately 10 cc total. After this, the patient was then prepped and draped in the usual sterile fashion. A #15 Bard-Parker was then utilized to make a skin incision horizontally, approximately 5 cm on either side from midline. After this, a blunt dissection was then utilized to dissect the subcutaneous fat from the platysmal muscle. There appeared to be a natural dehiscence of the platysma in the midline. A sub-platysmal dissection was then performed in the superior, inferior, and lateral directions with the help of a bear claw, Metzenbaum scissors and DeBakey forceps. Any bleeding was controlled with monopolar cauterization. After this, the two anterior large jugular veins were noted and resected laterally. The patient's trachea appeared to be slightly deviated to the right with identification finally of the midline raphe, off midline to the right. This was grasped on either side with a DeBakey forceps and dissected with monopolar cauterization and dissected with a Metzenbaum scissors. After this was dissected, the sternohyoid muscles were resected laterally and separated from the sternothyroid muscles. The sternothyroid muscles were then bluntly freed and dissected from the right thyroid gland. After this, attention was then drawn to the left gland, where the sternothyroid muscle was dissected bluntly on this side utilizing finger dissection and Kitners. The left thyroid gland was freed initially superiorly and worked inferiorly and laterally until the gland was pulled from the substernal region by blunt dissection and reflected and pulled anteriorly. After this, the superior and inferior parathyroid glands were noted. The dissection was carried very close to the thyroid gland to try to select these parathyroids posteriorly. After this, the superior pole was then identified and the superior laryngeal artery and vein were cross clamped and tied with __________ undyed Vicryl tie. The superior pole was finally freed and a small little feeding branched vessels from this area were cauterized with the bipolar cautery and cut with Metzenbaum scissors. After this, the thyroid gland was further freed down to the level of the Berry's ligament inferiorly and the dissection was carried once again more superiorly. The fine stats were then utilized to dissect along the superior aspect of the recurrent laryngeal nerve on the left side with freeing of the connective Berry's ligament tissue from the gland with the bipolar cauterization and the fine stat. Finally, attention was then drawn back to the patient's right side where the gland was rotated more anteriorly with fine dissection utilizing a fine stat to reflect the superior and inferior parathyroid glands laterally and posteriorly. The recurrent laryngeal nerve on this side was identified and further dissection was carried superiorly and anteriorly through this nerve to finally free the right side of the gland to Berry's ligament. The middle thyroid vein and inferior thyroid arteries were cross clamped and tied with #2-0 undyed Vicryl ties and also bipolared with the bipolar cauterization bilaterally. The Berry's ligament was then finally freed and the gland was then passed to scrub tech and passed off the field to Pathology. The neck was then thoroughly irrigated with normal saline solution and further bleeding was controlled with bipolar cauterization. After this, Surgicel was then placed in the bilateral neck regions and a #10 Jackson-Pratt drain was then placed within the left neck region with some extension over to the right neck region. This was brought out through the inferior skin incision and secured to the skin with a #2-0 nylon suture. The strap muscles were then reapproximated with a running #3-0 Vicryl suture followed by reapproximation of the platysma and subcutaneous tissue with a #4-0 undyed Vicryl. The skin was then reapproximated with a #5-0 Prolene subcuticular along with a #6-0 fast over the top. After this, Mastisol Steri-Strips and Bacitracin along with a sterile dressing and a __________ dressing were then placed. The patient intraoperatively did have approximately 50 cc of bloody drainage from this area within the JP drain. The patient was then turned back to Anesthesia, extubated in the operating room and transferred to Recovery in stable condition. The patient tolerated the procedure well and remained stable throughout.

  • 240.9; E04.9; 60240
  • 241.0; E04.1; 60252
  • 240.0; E04.0; 60220
  • 241.1; E04.2; 60200

Answer