OUTPATIENT ICD-9 AND ICD-10-CM CODING

Medical Specialty: Orthopedic - Musculoskeletal

Ankle sprain

Description:

History and Physical for right ankle sprain

CHIEF COMPLAINT:

Right ankle sprain.

HISTORY OF PRESENT ILLNESS:

This is a 56 year-old female who fell on November 26, 2007 at 11:30 a.m. while at the bank. She did not recall the specifics of her injury but she thinks that her right foot inverted and subsequently noticed pain in the right ankle. She describes no other injury at this time.

PAST MEDICAL HISTORY:

Hypertension and anxiety.

PAST SURGICAL HISTORY:

None.

MEDICATIONS:

She takes Lexapro and a blood pressure pill, but does not know anything more about the names and the doses.

ALLERGIES:

No known drug allergies.

SOCIAL HISTORY:

The patient lives here locally. She does not report any significant alcohol or illicit drug use. She works full time.

FAMILY HISTORY:

Noncontributory.

REVIEW OF SYSTEMS:

Pulm:

No cough, No wheezing, No shortness of breath

CV:

No chest pain or palpitations

GI:

No abdominal pain. No nausea, vomiting, or diarrhea.

PHYSICAL EXAM:

GENERAL APPEARANCE:

No acute distress

VITAL SIGNS:

Temperature 97.8, blood pressure 122/74, heart rate 76, respirations 24, weight 250 lbs, O2 sat 95% on R.A.

NECK:

Supple. No lymphadenopathy. No thyromegaly.

CHEST:

Clear to auscultation bilaterally.

HEART:

Regular rate and rhythm. No murmurs.

ABDOMEN:

Non-distended, nontender, normal active bowel sounds.

EXTREMITIES:

No Clubbing, No Cyanosis, No edema.

MUSCULOSKELETAL:

The spine is straight and there is no significant muscle spasm or tenderness there. Both knees appear to be non-traumatic with no deformity or significant tenderness. The right ankle has some swelling just below the right lateral malleolus and the dorsum of the foot is tender. There is decreased range of motion and some mild ecchymosis noted around the ankle.

DIAGNOSTIC DATA:

X-ray of the right ankle reveals no acute fracture by my observation. Radiologic interpretation is pending.

IMPRESSION:

Right ankle sprain.

PLAN:

  • Motrin 800 mg t.i.d.
  • Tylenol 1 gm q.i.d. as needed.
  • Walking cast is prescribed.
  • I told the patient to call back if any problems. The next morning she called back complaining of worsening pain and I called in some Vicodin ES 1-2 p.o. q. 8 hours p.r.n. pain #60 with no refills.
  • 845.02, E886.9, E849.8; S93.411A, V00.388A, Y92.89
  • 845.01, E888.8, E849.6; S93.421A, W18.30XA, Y92.29
  • 845.03, E888.9, E849.7; S93.431A, W19.XXXA, Y92.233
  • 845.00, E885.9, E849.6; S93.401A, W01.0XXA, Y92.510

Answer

Knee erythema – Aspiration

Description:

Erythema of the right knee and leg, possible septic knee. Aspiration through the anterolateral portal of knee joint.

PREOPERATIVE DIAGNOSES:

Erythema of the right knee and leg, possible septic knee.

POSTOPERATIVE DIAGNOSES:

Erythema of the right knee superficial and leg, right septic knee ruled out.

INDICATIONS:

Mr. ABC is a 52 year-old male who has had approximately eight days of erythema over his knee. He has been to multiple institutions as an outpatient for this complaint. He has had what appears to be prepatellar bursa aspirated with little to no success. He has been treated with Kefzol and 1 g of Rocephin at one point. He also reports, in the emergency department today, an attempt was made to aspirate his actual knee joint which was unsuccessful. Orthopedic Surgery was consulted at this time. Considering the patient's physical exam, there is a portal that would prove to be outside of the erythema that would be useful for aspiration of the knee. After discussion of risks and benefits, the patient elected to proceed with aspiration through the anterolateral portal of his knee joint.

PROCEDURE:

The patient's right anterolateral knee area was prepped with Betadine times two and a 20-gauge spinal needle was used to approach the knee joint approximately 3 cm anterior and 2 cm lateral to the superolateral pole of the patella. The 20-gauge spinal needle was inserted and entered the knee joint. Approximately, 4 cc of clear yellow fluid was aspirated. The patient tolerated the procedure well.

DISPOSITION:

Based upon the appearance of this synovial fluid, we have a very low clinical suspicion of a septic joint. We will send this fluid to the lab for cell count, crystal exam, as well as culture and Gram stain. We will follow these results. After discussion with the emergency department staff, it appears that they tend to try to treat his erythema which appears to be cellulitis with IV antibiotics.

  • 719.06; M25.461; 20605-RT
  • 695.9; L53.9; 20610-RT
  • 719.46; M25.561; 20615-RT
  • 695.89; L53.8; 10061-RT

Answer

HNP - Anterior cervical discectomy and fusion

Description:

Herniated nucleus pulposus, C5-C6, with spinal stenosis. Anterior cervical discectomy with fusion C5-C6.

PREOPERATIVE DIAGNOSIS:

Herniated nucleus pulposus, C5-C6, with spinal stenosis.

POSTOPERATIVE DIAGNOSIS:

Herniated nucleus pulposus, C5-C6, with spinal stenosis.

PROCEDURE:

Anterior cervical discectomy with fusion C5-C6.

PROCEDURE IN DETAIL:

The patient was placed in supine position. The neck was prepped and draped in the usual fashion. An incision was made from midline to the anterior border of the sternocleidomastoid in the right side. Skin and subcutaneous tissue were divided sharply. Trachea and esophagus were retracted medially. Carotid sheath was retracted laterally. Longus colli muscles were dissected away from the vertebral bodies of C5-C6. We confirmed our position by taking intraoperative x-rays. We then used the operating microscope and cleaned out the disk completely. We then sized the interspace and then tapped in a #7 mm cortical cancellous graft. We then used the DePuy Dynamic plate with 14-mm screws. Jackson-Pratt drain was placed in the prevertebral space and brought out through a separate incision. The wound was closed in layers using 2-0 Vicryl for muscle and fascia. The blood loss was less than 10-20 mL. No complication. Needle count, sponge count, and cottonoid count was correct.

  • 721.0, 723.1; M47.812, M54.2; 22554
  • 721.1, 723.2; M47.12, M53.0; 22600
  • 722.0, 723.0; M50.22, M48.02; 22551
  • 721.5, 724.00; M48.20, M48.00; 22554

Answer

Torn rotator cuff - Repair

Description:

Primary right shoulder arthroscopic rotator cuff repair with subacromial decompression.

PROCEDURE:

Primary right shoulder arthroscopic rotator cuff repair with subacromial decompression.

PATIENT PROFILE:

This is a 42 year-old female. Refer to note in patient chart for documentation of history and physical. Due to the nature of the patient's increasing pain, surgery is recommended. The alternatives, risks and benefits of surgery were discussed with the patient. The patient verbalized understanding of the risks as well as the alternatives to surgery. The patient wished to proceed with operative intervention. A signed and witnessed informed consent was placed on the chart. Prior to initiation of the procedure, patient identification and proposed procedure were verified by the surgeon in the pre-op area, and the operative site was marked by the patient and verified by the surgeon.

PRE-OP DIAGNOSIS:

Acute complete tear of the supraspinatus, Shoulder impingement syndrome.

POST-OP DIAGNOSIS:

Acute complete tear of the supraspinatus, Shoulder impingement syndrome.

ANESTHESIA:

General - Endotracheal.

FINDINGS:

ACROMION:

  • There was a medium-sized (5 - 10 mm) anterior acromial spur.
  • The subacromial bursa was inflamed.
  • The subacromial bursa was thickened.
  • There was thickening of the coracoacromial ligament.

LIGAMENTS / CAPSULE:

Joint capsule within normal limits.

LABRUM:

The labrum is within normal limits.

ROTATOR CUFF:

Full thickness tear of the supraspinatus tendon, 5 mm anterior to posterior, by 10 mm medial to lateral. Muscles and Tendons: The biceps tendon is within normal limits.

JOINT:

Normal appearance of the glenoid and humeral surfaces.

DESCRIPTION OF PROCEDURE:

PATIENT POSITIONING:

Following induction of anesthesia, the patient was placed in the beach-chair position on the standard operating table. All body parts were well padded and protected to make sure there were no pressure points. Subsequently, the surgical area was prepped and draped in the appropriate sterile fashion with Betadine.

INCISION TYPE:

  • Scope Ports: Anterior Portal.
  • Scope Ports: Posterior Portal.
  • Scope Ports: Accessory Anterior Portal.

INSTRUMENTS AND METHODS:

  • The arthroscope and instruments were introduced into the shoulder joint through the arthroscopic portals.
  • The subacromial space and bursa, biceps tendon, coracoacromial and glenohumeral ligaments, biceps tendon, rotator cuff, supraspinatus, subscapularis, infraspinatus, teres minor, capsulo-labral complex, capsule, glenoid labrum, humeral head, and glenoid, including the inner and outer surfaces of the rotator cuff, were visualized and probed.
  • The subacromial bursa, subacromial soft tissues and frayed rotator cuff tissue were resected and debrided using a motorized resector and 4.5 Synovial Resector.
  • The anterior portion of the acromion and acromial spur were resected with the 5.5 acromionizer burr. Approximately 5 mm of bone was removed. The coracoacromial ligament was released with the bony resection. The shoulder joint was thoroughly irrigated.
  • The edges of the cuff tissue were prepared, prior to the fixation, using the motorized resector.
  • The supraspinatus tendon was reattached and sutured using the arthroscopic knot pusher and Mitek knotless anchor system and curved pointed suture passer and large bore cannula (to pass the sutures). The repair was accomplished in a side-to-side and a tendon-to-bone fashion using three double loaded Mitek G IV suture anchors with 1 PDS suture.
  • The repair was stable to palpation with the probe and watertight.
  • The arthroscope and instruments were removed from the shoulder.

PATHOLOGY SPECIMEN:

No pathology specimens.

WOUND CLOSURE:

The joint was thoroughly irrigated with 7 L of sterile saline. The portal sites were infiltrated with 1% Xylocaine. The skin was closed with 4-0 Vicryl using interrupted subcuticular technique.

DRAINS / DRESSING:

Applied sterile dressing including gauze, iodoform gauze and Elastoplast.

SPONGE / INSTRUMENT / NEEDLE COUNTS:

Final counts were correct.

INTRAOPERATIVE MEDICATIONS:

No transfusions; minimal blood loss.

CAST / IMMOBILIZATION:

The extremity was immobilized in a shoulder immobilizer.

PATIENT TO RECOVERY ROOM:

The patient tolerated the procedure well, and was brought to the recovery room in good condition.

COMPLICATIONS:

No Immediate Complications.

POST-OP PLAN:

DISCHARGE ORDERS:

DISPOSITION:

Discharge patient to home upon release from Post-Op Recovery.

MEDICATIONS:

Hydrocodone/Acetaminophen (Vicodin 5/500) 1-2 tabs PO q 6 hr PRN.

ACTIVITY:

The patient may shower as tolerated.

FOLLOW-UP:

Appointment to Orthopedics Clinic within several days.

  • 727.61, 726.2; M75.122, M75.42; 29827-RT, 29826-RT
  • 726.19, 726.11; M75.80, M75.30; 29826-RT
  • 726.10, 727.49; M75.100, M71.312; 29827-RT
  • 726.10, 727.89; M75.102, M71.812; 29827-RT, 29826-RT-51

Answer

Bilateral L5 spondylolysis

Description:

Bilateral L5 spondylolysis with pars defects and spinal instability with radiculopathy. Chronic pain syndrome.

ADMISSION DIAGNOSIS:

Bilateral L5 spondylolysis with pars defects and spinal instability with radiculopathy.

SECONDARY DIAGNOSIS:

Chronic pain syndrome.

PRINCIPAL PROCEDURE:

L5 Gill procedure with interbody and posterolateral (360 degrees circumferential) arthrodesis using cages, bone graft, recombinant bone morphogenic protein, and pedicle fixation. This was performed by Dr. X on 01/08/08.

BRIEF HISTORY OF HOSPITAL COURSE:

The patient is a man with a history of longstanding back, buttock, and bilateral leg pain. He was evaluated and found to have bilateral pars defects at L5-S1 with spondylolysis and instability. He was admitted and underwent an uncomplicated surgical procedure as noted above. In the postoperative period, he was up and ambulatory. He was taking p.o. fluids and diet well. He was afebrile. His wounds were healing well. Subsequently, the patient was discharged home.

DISCHARGE MEDICATIONS:

Discharge medications included his usual preoperative pain medication as well as other medications.

FOLLOWUP:

At this time, the patient will follow up with me in the office in six weeks' time. The patient understands discharge plans and is in agreement with the discharge plan. He will follow up as noted.

  • 737.8, 724.2, 338.19; M43.8X9, M54.5, R52
  • 738.5, 724.3, 338.18; M99.83, M54.30, G89.18
  • 738.4, 724.4, 338.4; M43.07, M54.17, G89.4
  • 737.40, 724.4, 338.0; M43.8X9, M54.16, G89.0

Answer

Hip pain

Description:

A woman presenting to our clinic for the first time for evaluation of hip pain, right greater than left, of greater than 2 years duration. The pain is located laterally as well as anteriorly into the groin.

HISTORY OF PRESENT ILLNESS:

The patient is a 38 year-old woman presenting to our clinic for the first time for evaluation of hip pain, right greater than left, of greater than 2 years duration. The patient states that she began with right hip pain getting steadily worse over the last 2 years and has now developed some pain in the left hip. The pain is located laterally as well as anteriorly into the groin. She states that the pain is present during activities such as walking, and she does get some painful popping and clicking in the right hip. She is here for evaluation for the first time. She sought no previous medical attention for this.

PAST MEDICAL HISTORY:

Significant for depression and reflux disease.

PAST SURGICAL HISTORY:

Cesarean section x 2.

CURRENT MEDICATIONS:

Listed in the chart and reviewed with the patient.

ALLERGIES:

The patient has no known drug allergies.

SOCIAL HISTORY:

The patient is married. She is employed as an office manager. She does smoke cigarettes, one pack per day for the last 20 years. She consumes alcohol 3 to 5 drinks daily. She uses no illicit drugs. She exercises monthly mainly walking and low impact aerobics. She also likes to play softball.

REVIEW OF SYSTEMS:

Significant for occasional indigestion and nausea as well as anxiety and depression. The remainder of the systems negative.

PHYSICAL EXAMINATION:

The patient is 5 foot, 2 inches tall, weighs 155 pounds. The patient ambulates independently without an assist device with normal stance and gait. Inspection of the hips reveals normal contour and appearance and good symmetry. The patient is able to do an active straight leg raise against gravity and against resistance bilaterally. She has no significant trochanteric tenderness. She does, however, have some tenderness in the groin bilaterally. There is no crepitus present with passive or active range of motion of the hips. She is grossly neurologically intact in the bilateral lower extremities.

DIAGNOSTIC DATA:

X-rays performed today in the clinic include an AP view of the pelvis and a frog-leg lateral of the right hip. There are no acute findings. No fractures or dislocations. There are minimal degenerative changes noted in the joint. There is, however, the suggestion of an exostosis on the superior femoral neck, which could be consistent with femoroacetabular impingement.

IMPRESSION:

Bilateral hip pain, right worse than left, possibly suggesting femoroacetabular impingement based on x-rays and her clinical picture is also consistent with possible labral tear.

PLAN:

After discussing possible diagnoses with the patient, I have recommended that we get MRI arthrograms of the bilateral hips to evaluate the anatomy and especially concentrating on the labrum in the right hip. We will get that done as soon as possible. In the meantime, she is asked to moderate her activities. She will follow up as soon as the MRIs are performed.

  • 337.22; G90.529
  • 719.40; M25.50
  • 719.55; M25.651, M25.652
  • 719.45; M25.551, M25.552

Answer

De Quervain - Release

Description:

Wrist de Quervain stenosing tenosynovitis. de Quervain release. Fascial lengthening flap of the 1st dorsal compartment.

PREOPERATIVE DIAGNOSIS:

Left wrist de Quervain stenosing tenosynovitis.

POSTOPERATIVE DIAGNOSIS:

Left wrist de Quervain stenosing tenosynovitis.

TITLE OF PROCEDURES

  • De Quervain release.
  • Fascial lengthening flap of the 1st dorsal compartment.

ANESTHESIA:

MAC.

COMPLICATIONS:

None.

PROCEDURE IN DETAIL:

After MAC anesthesia and appropriate antibiotics were administered, the left upper extremity was prepped and draped in the usual standard fashion. The arm was exsanguinated with an Esmarch and the tourniquet inflated to 250 mmHg.

I made a transverse incision just distal to the radial styloid. Dissection was carried down directly to the 1st dorsal compartment with the superficial radial nerve identified and protected. Meticulous hemostasis was maintained with bipolar electrocautery.

I dissected the sheath superficially free of any other structures, specifically the superficial radial nerve. I then incised it under direct vision dorsal to its axis and incised it both proximally and distally. The EPB subsheath was likewise released.

I irrigated the wound thoroughly. In order to prevent tendon subluxation, I then back-cut both the dorsal and volar leafs of the sheath so that I could close them in an extended and lengthened position. I did this with 3-0 Vicryl. I then passed an instrument underneath to check and make sure that the sheath was not too tight. I then irrigated it and closed the skin, and then I dressed and splinted the wrist appropriately. The patient was sent to the recovery room in good condition, having tolerated the procedure well.

  • 727.40; M71.30; 25001-LT
  • 727.04; M65.4; 25000-LT
  • 727.41; M67.432; 25270-LT
  • 727.03; M65.322; 25230-LT

Answer

Dupuytren - Excision

Diagnosis:

Dupuytren disease right hand and fifth finger

Procedure:

Excision Dupuytren disease

Complications:

None

Blood Loss:

Minimal

Anesthesia:

Bier block with monitored anesthesia

Indications:

The patient is a 51 year-old male with a history of Dupuytren's disease causing contractions. This is painful for the patient, and he is in obvious discomfort. The risks and benefits of surgery have been discussed with the patient and he wishes to continue with the excision.

Procedure:

The patient was supine on the procedure table. A bier block was administered to the right upper arm by the anesthesiologist. The right hand and wrist were prepped and draped in sterile fashion.

A zig-zag incision was made on the palmar surface from the distal finger to the mid palm area. Skin flaps were elevated. Dupuytren contracture (palmar fascia) was dissected from the undersurface of the skin flaps. Two proximal neurovascular bundles were identified. The Dupuytren fibrous band was resected proximally with tissue restoration. Palmar fascia was dissected from the neurovascular bundles from the palmar flexor tendon sheath continuing to the right fifth finger PIP joint. The wound was irrigated. Inspection of the neurovascular bundles showed no evidence of injury or residual Dupuytren disease. Incisions were closed with interrupted 5-0 nylon sutures. A dry dressing was applied.

The patient tolerated the procedure well and will be monitored until discharge. He is to return to the office for wound check and suture removal.

  • 728.4; M24.20; 26121-RT
  • 728.6; M72.0; 26123-RT
  • 729.89; R29.898; 26121-RT
  • 729.82; R25.2; 26121-RT

Answer

Ganglion - Excision

Description:

Excision of ganglion of the left wrist. A curved incision was made over the presenting ganglion over the dorsal aspect of the wrist.

PREOPERATIVE DIAGNOSIS:

Ganglion of the left wrist.

POSTOPERATIVE DIAGNOSIS:

Ganglion of the left wrist.

OPERATION:

Excision of ganglion.

ANESTHESIA:

General.

ESTIMATED BLOOD LOSS:

Less than 5 mL.

OPERATION:

After a successful anesthetic, the patient was positioned on the operating table. A tourniquet applied to the upper arm. The extremity was prepped in a usual manner for a surgical procedure and draped off. The superficial vessels were exsanguinated with an elastic wrap and the tourniquet was then inflated to the usual arm pressure. A curved incision was made over the presenting ganglion over the dorsal aspect of the wrist. By blunt and sharp dissection, it was dissected out from underneath the extensor tendons and the stalk appeared to arise from the distal radiocapitellar joint and the dorsal capsule was excised along with the ganglion and the specimen was removed and submitted. The small superficial vessels were electrocoagulated and instilled after closing the skin with 4-0 Prolene, into the area was approximately 6 to 7 mL of 0.25 Marcaine with epinephrine. A Jackson-Pratt drain was inserted and then after the tourniquet was released, it was kept deflated until at least 5 to 10 minutes had passed and then it was activated and then removed in the recovery room. The dressings applied to the hand were that of Xeroform, 4x4s, ABD, Kerlix, and elastic wrap over a volar fiberglass splint. The tourniquet was released. Circulation returned to the fingers. The patient then was allowed to awaken and left the operating room in good condition.

  • 727.41; M67.432; 25111-RT
  • 727.42; M67.432; 25112-RT
  • 727.41; M67.49; 25075-RT
  • 727.42; M67.49; 25035-RT

Answer

Knee cartilage loose body - Removal

Description:

Left knee arthroscopy with removal of the cartilage loose body and microfracture of the medial femoral condyle with chondroplasty.

PREOPERATIVE DIAGNOSIS:

Left knee medial femoral condyle osteochondritis dissecans.

POSTOPERATIVE DIAGNOSIS:

Left knee medial femoral condyle osteochondritis dissecans.

PROCEDURES:

Left knee arthroscopy with removal of the cartilage loose body and microfracture of the medial femoral condyle with chondroplasty.

ANESTHESIA:

General.

TOURNIQUET TIME:

Thirty-seven minutes.

MEDICATIONS:

The patient also received 30 mL of 0.5% Marcaine local anesthetic at the end of the case.

COMPLICATIONS:

No intraoperative complications.

DRAINS AND SPECIMENS:

None.

INTRAOPERATIVE FINDINGS:

The patient had a loose body that was found in the suprapatellar pouch upon entry of the camera. This loose body was then subsequently removed. It measured 24 x 14 mm. This was actually the OCD lesion seen on the MRI that had come from the weightbearing surface of just the lateral posterior aspect of the medial femoral condyle.

HISTORY AND PHYSICAL:

The patient is 13 year-old male with persistent left knee pain. He was initially seen at Sierra Pacific Orthopedic Group where an MRI demonstrated unstable OCD lesion of the left knee. The patient presented here for a second opinion. Surgery was recommended grossly due to the instability of the fragment. Risks and benefits of surgery were discussed. The risks of surgery include risk of anesthesia, infection, bleeding, changes in sensation and motion extremity, failure to relieve pain or restore the articular cartilage, possible need for other surgical procedures, and possible early arthritis. All questions were answered and parents agreed to the above plan.

DESCRIPTION OF PROCEDURE:

The patient was taken to the operating room and placed supine on the operating table. General anesthesia was then administered. The patient received Ancef preoperatively. A nonsterile tourniquet was placed on the upper aspect of the patient's left thigh. The extremity was then prepped and draped in standard surgical fashion. The standard portals were marked on the skin. The extremity was wrapped in Esmarch prior to inflation of tourniquet to 250 mmHg. The portal incisions were then made by an #11 blade. Camera was inserted into the lateral joint line. There was a noted large cartilage loose body in the suprapatellar pouch. This was subsequently removed with extension of the anterolateral portal. Visualization of the rest of the knee revealed significant synovitis. The patient had a large cartilage defect in the posterolateral aspect of the medial femoral condyle. The remainder of the knee demonstrated no other significant cartilage lesions, loose bodies, plica or meniscal pathology. ACL was also visualized to be intact in the intracondylar notch.

Attention was then turned back to the large defect. The loose cartilage was debrided using a shaver. Microfracture technique was then performed to 4 mm depth at 2 to 3 mm distances. Tourniquet was released at the end of the case to ensure that there was fat and bleeding at the microfracture sites. All instruments were then removed. The portals were closed using #4-0 Monocryl. A total of 30 mL of 0.5% Marcaine was injected into the knee. Wounds were then cleaned and dried, and dressed in Steri-Strips, Xeroform, 4 x 4s, and bias. The patient was then placed in a knee immobilizer. The patient tolerated the procedure well. The tourniquet was released at 37 minutes. He was taken to recovery in stable condition.

POSTOPERATIVE PLAN:

The loose cartilage fragment was given to the family. The intraoperative findings were relayed with intraoperative photos. There was a large deficit in the weightbearing portion of medial femoral condyle. His prognosis is guarded given the fact of the fragile lesion and location, but in advantages of his age and his rehab potential down the road, if the patient still has symptoms, he may be a candidate for osteochondral autograft, a procedure which is not performed at Children's or possible cartilaginous transplant. All questions were answered. The patient will follow up in 10 days, may wet the wound in 5 days.

  • 727.41; M67.462; 29871-LT
  • 916.6; S80.252A; 29877-LT
  • 732.7; M93.262; 29874-LT
  • 730.06; M86.169; 29886-LT

Answer