Inpatient OP Note Patient Case Number: IPSX16-Santiago,

Inpatient OP Note Patient Case Number: IPSX16-Santiago, Cole Patient Name: Cole Santiago DOB: 09-27-59 Sex: M Date of Service: 03-02-XX Surgeon: Brian Carlisle, MD Pre-Operative Diagnosis Hemopericardium and pericardial tamponade Post-Operative Diagnosis Hemopericardium and pericardial tamponade Procedure Performed: Emergent subxiphoid pericardial window Anesthesia: General Complications: None Indication for Procedure: Mr. Santiago is a 59-year-old gentleman who had undergone a cardiac ablation in the catheterization laboratory earlier today. At that time, hemopericardium was diagnosed and a small catheter was placed into the pericardial space. Blood was evacuated and then the small catheter no longer was draining. There still appeared to be blood in that pericardial space. There was evidence of pericardial tamponade. Pericardial drainage and possible mediastinal exploration was recommended. Description of Procedure: The patient was taken emergently from the CCU to the operating room. He was prepped and draped, and once that had been done, he was then intubated. Shortly after intubation, the subxiphoid approach was used. The pericardium was identified and a small incision was made in the pericardium. A 500 mL of dark blood was then drained from the pericardium. The opening in the pericardium was enlarged and right-angle chest tube was placed along the diaphragmatic surface in the pericardial space. The tube exited through a separate stab incision. The incision was then closed in the usual fashion. The patient tolerated the procedure well and left the operating room in satisfactory condition. WHAT WOULD BE THE CORRECT ICD-10-CM & ICD-10-PCS CODES AND EXPLAIN? SCIENCE HEALTH SCIENCE NURSING NURSING 1341

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