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Sample Surgery Medical report for Medical coders

PREOPERATIVE DIAGNOSES: Rule out rotator cuff tear of the right shoulder.

POSTOPERATIVE DIAGNOSES: 1. Partial thickness tear of supraspinatus, right shoulder.

  1. Type II superior labral tear, right shoulder.

  2. Degenerative joint disease with chondral injury and multiple loose bodies intraarticularly, right shoulder.

OPERATIVE PROCEDURES:

ANESTHESIA: General endotracheal.

ESTIMATED BLOOD LOSS: Minimal.

Sample Surgery Medical report for Medical coders

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DESCRIPTION OF PROCEDURE:

The patient was taken to the operating room in a supine position. After induction of general endotracheal anesthesia, the patient was placed in the left lateral decubitus position. The right shoulder was then prepped and draped in the usual sterile fashion. Shoulder examination under anesthetic showed no evidence of instability. Subacromial portals were made and there was noted to be severe bursitis. The bursa was resected and significant hooking of the anterior acromion was noted and this area was debrided to a good smooth border. There was noted to be a partial thickness tearing of the supraspinatus with only involving about 15% of the tendon. This area was debrided. No full thickness tearing was noted. At this point, the joint was entered. A rather severe injury was noted of the humeral head measuring about 2 cm in diameter with significant fibrillation and flap formation along the edges. The chondral edges were debrided with a shaving blade through an anterior portal and several large cartilaginous loose bodies were removed. The superior labrum was noted to have type II tear and the anterior labrum was frayed, but no obvious tearing noted.

At this point, through the anterior portal, two #2 FiberWire sutures were placed through the anterior and posterior root of the biceps anchor and these were both secured using 3.5 mm Arthrex PushLock implants. Once this was done, excellent stability of the superior labrum was noted. At this point, the arthroscope was removed and Marcaine infiltrated into the subacromial space. A 4-0 Monocryl was used to close the portals. Sterile dressing and sling was applied. The patient was then extubated and brought to recovery room in stable condition. An assistant was used for this case. The assistant was integral in handling the arthroscope, helping placement of implants, and wound closure.

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