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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.
Type II superior labral tear, right shoulder.
Degenerative joint disease with chondral injury and multiple loose bodies intraarticularly, right shoulder.
OPERATIVE PROCEDURES:
ANESTHESIA: General endotracheal.
ESTIMATED BLOOD LOSS: Minimal.
DESCRIPTION OF PROCEDURE:
