DRNP- 6540 Week 1 Main Discussion Post Mrs. Chow, an

Case 6: Operative Report PREOPERATIVE DIAGNOSIS: Post tonsillectomy hemorrhage POSTOPERATIVE DIAGNOSIS: Post tonsillectomy hemorrhage NAME OF PROCEDURE: Control of post tonsillectomy hemorrhage CLINICAL INDICATIONS/PROCEDURE DESCRIPTION/FINDINGS: ANESTHESIA: General endotracheal ESTIMATED BLOOD LOSS: Less than 5 cc in the OR INDICATIONS: Isaiah is a 14-year- old male who is postoperative day 6, status post tonsillectomy and adenoidectomy. He presents with his second post tonsillectomy bleed. FINDINGS: He had large clot on the right and small clot on the left. He had a mid tonsillar active venous bleed on the right, along with diffuse granulation tissue that was also very friable. Very similar findings on the left. No pulsatile bleeding. DESCRIPTION OF PROCEDURE: The patient was met in the preoperative area. The risks and benefits of the procedure were explained and consent was signed. He was taken to the operating room with Anesthesia, placed under general anesthesia with endotracheal intubation. A time-out was performed and the patient was correctly identified. The McIvor mouth gag was inserted and mouth retracted open, and he was placed in suspension. There were large clots bilaterally. They were carefully removed and the sites that were bleeding were suction cauterized. Bipolar cautery was also used to cauterize a couple of locations. Good hemostasis was achieved. Copious amount of saline was then irrigated out the oral cavity. Stomach contents were suctioned out. There was minimal blood in the stomach. McIvor mouth gag was let down for 5 minutes to take off tension. It was retracted back open. The remaining small areas that were bleeding were treated with bipolar cautery. The 12 2: ICD-10- PCS Coding Guidelines gag was let back down. When it was retracted open there was still good hemostasis. McIvor mouth gag was removed. He was turned over to the care of Anesthesia. He was awakened in the operating room and taken to the recovery area in stable condition. Plan: We will admit and obtain a hematology consult. 1. What is the objective of this procedure? 2. What root operation is used to reflect this objective? 3. There are only four body systems available for this root operation. Which body system is selected for this case? 4. What body part is selected? 5. What is the approach for the procedure? 6. Is there a coding guideline that assists with this coding decision? 7. What is the code for this procedure?

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