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Exam 8: Musculoskeletal System

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Question 1

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Case -T8-1A OPERATIVE REPORT, TOTAL KNEE ARTHROPLASTY LOCATION: Inpatient, Hospital PATIENT: Sandra Bowie SURGEON: Mohomad Almaz, MD ATTENDING PHYSICIAN: Mohomad Almaz, MD PREOPERATIVE DIAGNOSIS: Medial compartment and patellofemoral component osteoarthritis, left knee. Posttraumatic varus deformity, left proximal tibia. POSTOPERATIVE DIAGNOSIS: Medial compartment and patellofemoral component osteoarthritis, left knee. Posttraumatic varus deformity, left proximal tibia. PROCEDURE PERFORMED: Left cemented Duracon total knee arthroplasty COMPONENTS UTILIZED: Duracon medium femur, M1 tibia, 16-mm (millimeter) posterior stabilized tibial insert, and 20-mm symmetric patella OPERATIVE PROCEDURE: After suitable general anesthesia had been achieved, the patient's left knee was prepped and draped in the usual manner. Prior to prepping, a thigh tourniquet was applied. Initially this was not inflated. A long anterior midline skin incision was made. Long anterior capsulotomy was performed. Capsular bleeders were cauterized, as were skin and synovial bleeders. The tourniquet was then inflated to 300 mmHg after the leg was stripped with an Esmarch. Entry hole was made in the distal femur. Intramedullary alignment device was used to make the distal cut; 10 mm of bone was resected. Anterior referencing instrument was used. The anterior shim cut was made. Proximal tibial cut was performed. Due to the ramus deformity of the proximal tibia from a previous fracture, about 2 mm of bone was excised medially and about 12 mm laterally. This corrected the varus deformity. The extension gap was then checked. It was felt that a 13-flexion gap would provide an equivalent degree of tightness. This flexion gap was measured. The femur was then sized, and it was felt that a medium femur would reproduce this flexion gap. The 4-in-1 block was applied. Anterior posterior chamber cuts were performed. Trial femoral and tibial prosthesis were performed. The patient was noted to have some increased laxity and flexion. To tighten this up further, 2 mm of bone was excised off the distal femur. Inserter was upgraded to 16 mm, and with this there was good stability and flexion in extension and good alignment. The patella was then prepared for resurfacing technique. The patient had severe wear laterally, so 8 mm of bone was excised; 29-mm symmetric trial component was placed. This tracked well with the hands-off test. Box was then cut in the femur for the posterior stabilized component. Slot was cut in the tibia for the keel of the tibial component. Rotation of the tibial component was taken off of the medial third of the tibial tubercle. The joint was then thoroughly irrigated. Lug holes were then filled with bone graft from the bone trimmings. The M-1 tibia, medium femur, and 29-mm patella were then inserted; 60-mm insert was then placed and the leg held in extension until the cement was hard. Trial insert was then removed. The cement was carefully removed from the margins of the prosthesis. The actual 60-mm posterior stabilized tibial insert was placed. Locking screw was placed. The knee joint was then thoroughly irrigated. Capsule was closed with #1 Panacryl, subcutaneous tissue with 2-0 Vicryl, and skin with staples. A dressing and a Robert Jones dressing with anterior plaster splint were then applied. The tourniquet was released. Following tourniquet release, good circulation was noted to return to the foot. The patient tolerated the procedure well and returned to the recovery room in stable condition. Please note that 1 g (gram) of vancomycin was added to each batch of cement due to the fact that the patient had had previous methicillin-resistant Staphylococcus aureus osteomyelitis of her foot. T8-1A: SERVICE CODE(S): ___________________________________________________ ICD-10-CM DX CODE(S): ______________________________________________

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Professional Services: 27447-LT (Arthroplasty, Knee) ICD-10-CM DX: M17.12 (Osteoarthritis), M21.162 (Deformity, varus NEC, knee) Explanation: The surgeon removed defective bones and then fitted the defect areas with prostheses (artificial knee components). This is a reconstruction of a defective knee or total knee arthroplasty in which the tibial component and the femoral component were replaced with prostheses that were glued into place. The patellar component was then replaced with a prosthetic device. The defect area was stabilized and the area closed in routine fashion. A total knee replacement or arthroplasty is reported with 27447 with modifier -LT to indicate the left side. The diagnosis is stated in the Postoperative Diagnosis section of the report as osteoarthritis of the left knee and reported with M17.12. The posttraumatic deformity of the left tibia is reported with M21.162.

Question 2

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Case -T8-2B OPERATIVE REPORT, CLOSED REDUCTION LOCATION: Outpatient, Hospital PATIENT: Mary Smith SURGEON: Mohomad Almaz, MD DIAGNOSIS: Right hand fifth metacarpal fracture shaft with angulatory and rotational change due to striking the hand against a closing door PROCEDURE PERFORMED: Closed reduction and percutaneous pinning of right hand fifth metacarpal PROCEDURE: After satisfactory level of general anesthesia was reached and patient was in the supine position, the extremity was prepped and draped. At this setting, we could translationally displace this fracture in a manner as to correct valgus and rotational anomaly. She remained somewhat subtly foreshortened and translationally opposed by about 1-2 mm (millimeter). At this setting, I accepted this as an acceptable reduction without opening of the skin. We proceeded with the advancement of a single .054 intramedullary pin. AP (anterior posterior), lateral, and oblique views at this time were confirmatory for restoration of alignment as noted fluoroscopically. The patient was then sandwich splint immobilized with ulnar gutter splint and transferred to the recovery room in a stable manner without complication or compromising events. T8-2B: SERVICE CODE(S): ___________________________________________________ ICD-10-CM DX CODE(S): ______________________________________________

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Professional services: 26608-RT (Fracture, Metacarpal, Percutaneous Fixation), 26605-51-RT (Fracture, Metacarpal, with Manipulation) ICD-10-CM DX: S62.326A (Fracture, traumatic, metacarpal, shaft), W22.8XXA (External Cause Index, Striking against, object) Explanation: The service is a reduction (26605) and a percutaneous fixation (26608) of the right hand with -RT used to indicate the right hand. The diagnosis is a fracture of the metacarpal shaft as stated in the Diagnosis section of the report and reported with S62.326A. External cause code W22.8XXA indicates the injury was sustained when the hand was struck against a moving object (door). The 7th character "A" indicates the initial encounter.

Question 3

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Case -T8-1B OPERATIVE REPORT, RIGHT CARPAL TUNNEL RELEASE LOCATION: Outpatient, Hospital PATIENT: Glory Ann Borden SURGEON: Mohomad Almaz, MD DIAGNOSIS: Right carpal tunnel syndrome PROCEDURE PERFORMED: Right carpal tunnel release PROCEDURE: The patient was placed in the supine position on the operating room table, where her right hand and forearm were prepped with Betadine and draped in a sterile fashion. We infiltrated the thenar crease area with 1% Xylocaine, and once adequate anesthesia had been achieved, we exsanguinated the hand and forearm with an Esmarch bandage. We then created a longitudinal incision just at the ulnar aspect of the thenar crease and carried the dissection down through the subcutaneous tissue. We identified the transverse carpal ligament and incised this both proximally and distally until we were certain that it was completely released. We identified the median nerve and found that it was free. We did spread the soft tissues surrounding it gently. We then released the tourniquet after 8 minutes of tourniquet time, and bleeding was controlled with pressure and also with electrocautery. We thoroughly irrigated the area with saline. We then closed the skin using 4-0 nylon suture, and a Xeroform dressing was applied under a small pressure dressing. She was taken from the operating room in good condition. She tolerated this very well. T8-1B: SERVICE CODE(S): ___________________________________________________ ICD-10-CM DX CODE(S): ______________________________________________

Case -AUDIT REPORT T8.1 OPERATIVE REPORT, CLOSED REDUCTION LOCATION: Outpatient, Hospital PATIENT: Kelli Klarkor SURGEON: Mohomad Almaz, MD DIAGNOSIS: Displaced fractured base, left first metacarpal PROCEDURE PERFORMED: Closed reduction of metacarpal fracture INDICATION: Kelli is a 15-year-old girl who fell while roller blading. She has now fractured her left thumb and will need manipulation to put it back in place. I have recommended a closed reduction and thumb spica cast application. The mother agrees with this. PROCEDURE: Under a satisfactory level of sedation, the fracture was carefully manipulated and a well-padded and very well-molded fiberglass cast was placed over the base of the thumb. After this was applied, we applied repeat mini C-arm views and confirmed improvement in position of the fracture but still not in anatomic position. Where it is presently, if it heals, it still will be completely functional. I reviewed this with the mother, and I have recommended that we cast this and re-manipulate it as the swelling goes down, and we will do this sometime next week. T8.1: SERVICE CODE(S): 26607-FA______________ ICD-10-CM DX CODE(S): S62.399A________ INCORRECT/MISSING CODE(S): ________________________________________

Case -AUDIT REPORT T8.2 OPERATIVE REPORT, SHOULDER LOCATION: Outpatient, Hospital PATIENT: Stan Hope SURGEON: Mohomad Almaz, MD PREOPERATIVE DIAGNOSIS: Left shoulder pain and numbness, past shoulder injury POSTOPERATIVE DIAGNOSIS: Normal shoulder PROCEDURE PERFORMED: Diagnostic arthroscopy, left shoulder CLINICAL HISTORY: This is a 57-year-old with a 10-year-old rotator cuff tear injury to his left shoulder. The patient does heavy lifting for a living. For the past 6 months the patient has been experiencing pain in this shoulder with some numbness and tingling traveling down the arm. X-rays were normal. Decision was made to go in with an arthroscope to try and uncover a reason for this pain and numbness. OPERATIVE REPORT: Under general anesthesia, the patient was laid in the beach chair position on the operating room table. The left shoulder was examined and found to be stable. There is full range of motion of this shoulder also. The extremity was then prepped and draped in the usual fashion. A standard posterior arthroscopic portal was created, and the camera was introduced. First the back of the joint was inspected, and this did not show any evidence of damage. The anterior ligament structures were normal. The biceps attachment and its transit through the joint were normal. Subscapularis was intact with no abnormality. Old scarring of the rotator cuff was noted. But all looked as it should. Nothing abnormal was seen. The camera was then removed out of the glenohumeral joint and placed in the subacromial space. There was excellent visualization of this area. No abnormalities could be identified, and there was no evidence of any impingements. The camera was then removed from the subacromial space. The area was then infiltrated with Marcaine. The posterior portal was then closed with absorbable sutures and Steri-Strips, and a Mepore dressing was placed on it. The arm was then placed in a sling; the patient awakened and was placed on his hospital bed and taken to the recovery room in good condition. T8.2: SERVICE CODE(S): 29805_____________________________________________ ICD-10-CM DX CODE(S): S43.422_______________________________________ INCORRECT/MISSING CODE(S): ________________________________________

Case -T8-2A OPERATIVE REPORT, REMOVAL OF CLAVICLE LOCATION: Outpatient, Hospital PATIENT: Larry Frost SURGEON: Mohomad Almaz, MD DIAGNOSIS: Localized degenerative arthritis, left distal clavicle, with persistence of arthritic symptoms OPERATIVE PROCEDURE: Removal of distal 1 cm (centimeter) left clavicle After satisfactory level of general anesthesia was reached and patient was in the supine position, he was further placed in a beach chair position. A longitudinal incision was created over the region of the left AC joint. At this time, sharp dissection was conducted down to the fascial plane. The fascial plane was then further incised, reflecting both the deltoid and the trapezial fascia and the distal aspect of the clavicle undermining the clavicle; at this time we simply proceeded excising the distal 1 cm of the clavicle with use of a reciprocal saw. With completion of this element of the procedure, the margins of the bone were otherwise unremarkable in gross appearance. It was also significant to note at this time the acromial end of the articulation was unremarkable. The wound was irrigated, followed by controlling of punctate bleeding with use of electrocautery, followed by the closure of the deltotrapezial fascia. At this time I further imbricated sutures for stable repair, followed by repair of subcutaneous and dermal planes. A simple dressing was applied. The patient tolerated the procedure well and was transported to the recovery room in a stable manner. T8-2A: SERVICE CODE(S): ___________________________________________________ ICD-10-CM DX CODE(S): ______________________________________________