Code the first operative report, include any CPT surgery code(s), anesthesia code(s), and any modifiers applicable. (20 points)
Code the E&M code for the second office visit.
1. Description: Bilateral open Achilles lengthening with placement of short leg walking cast.
PREOPERATIVE DIAGNOSIS: Idiopathic toe walker.POSTOPERATIVE DIAGNOSIS: Idiopathic toe walker.PROCEDURE: Bilateral open Achilles lengthening with placement of short leg walking cast.ANESTHESIA: Surgery performed under general anesthesia. A total of 10 mL of 0.5% Marcaine local anesthetic was used.COMPLICATIONS: No intraoperative complications.DRAINS: None.SPECIMENS: None.TOURNIQUET TIME: On the left side was 30 minutes, on the right was 21 minutes.HISTORY AND PHYSICAL: The patient is a 10-year-old boy who has been a toe walker since he started ambulating at about a year. The patient had some mild hamstring tightness with his popliteal angle of approximately 20 degrees bilaterally. He does not walk with a crouched gait but does toe walk. Given his tightness, surgery versus observation was recommended to the family. Family however wanted to correct his toe walking. Surgery was then discussed. Risks of surgery include risks of anesthesia, infection, bleeding, changes in sensation and motion of the extremities, failure to resolve toe walking, possible stiffness, cast, and cast problems. All questions were answered and parents agreed to above surgical plan.PROCEDURE IN DETAIL: The patient was taken to the operating room and placed supine on the operating table General anesthesia was then administered. The patient received Ancef preoperatively. The patient was then subsequently placed prone with all bony prominences padded. Two bilateral nonsterile tourniquets were placed on each thigh. Both extremities were then prepped and draped in a standard surgical fashion. We turned our attention first towards the left side. A planned incision of 1 cm medial to the Achilles tendon was marked on the skin. The extremity was wrapped in Esmarch prior to inflation of tourniquet to 250 mmHg. Incision was then made and carried down through subcutaneous fat down to the tendon sheath. Achilles tendon was identified and Z-lengthening was done with the medial distal half cut. Once Z-lengthening was completed proximally, the length of the Achilles tendon was then checked. This was trimmed to obtain an end-on-end repair with 0 Ethibond suture. This was also oversewn. Wound was then irrigated. Achilles tendon sheath was reapproximated using 2-0 Vicryl as well as the subcutaneous fat. The skin was closed using 4-0 Monocryl. Once the wound was cleaned and dried and dressed with Steri-Strips and Xeroform, the area was injected with 0.5% Marcaine. It was then dressed with 4 x 4 and Webril. Tourniquet was released at 30 minutes. The same procedure was repeated on the right side with tourniquet time of 21 minutes. While the patient was still prone, two short-leg walking casts were then placed. The patient tolerated the procedure well and was subsequently flipped supine on to hospital gurney and taken to PACU in stable condition.POSTOPERATIVE PLAN: The patient will be discharged on the day of surgery. He may weightbear as tolerated in his cast, which he will have for about 4 to 6 weeks. He is to follow up in approximately 10 days for recheck as well as prescription for intended AFOs, which he will need up to 6 months. The patient may or may not need physical therapy while his Achilles lengthenings are healing. The patient is not to participate in any PE for at least 6 months. The patient is given Tylenol No. 3 for pain.
2.
HISTORY OF PRESENT ILLNESS: Mr. Smith is a 63-year-old gentleman new to our Clinic. He had been followed by Dr. Jones at Kernodle Clinic. Mr. Smith has a past medical history that includes hypertension for more than five years. It sounds like he has fairly severe white coat hypertension. Apparently, he has home readings consistently 30 points below what he gets in the office. He had been on Capoten in the past and gotten a cough with that. He had been on Norvasc in the past, but then stopped it for unclear reasons. More recently, he has been on Hyzaar. He also has hypercholesterolemia and has been on Lipitor. He has for the past year or so felt that his hands and feet were “burning up” at night. He reports that “he can almost see the heat waves from them.” He thinks this is a medication side effect. On his own, he stopped his Lipitor three weeks ago. He has not noticed any difference in his symptoms. He otherwise feels well and has no complaints.
PAST MEDICAL HISTORY: 1. Hypertension. 2. Hypercholesterolemia. 3. Status post plastic surgery after a motor vehicle collision when he was in his 20s. 4. History of depression around the time of the accident. He does report that intermittently he feels quite down, but he is able “to pick himself back up”. More recently, however, he has been in a more prolonged period. 5. He has significant moles and he is followed by an outside dermatologist. 6. He has had normal PSA and rectal exams. He had a colonoscopy about five years ago and again one year ago, both of which showed many polyps, pathology not known.
MEDICATIONS: Now only Hyzaar, a baby aspirin and a multivitamin
ALLERGIES: Capoten caused a cough.
SOCIAL HISTORY: He works in computer software. He does not smoke. He drinks wine and Martinis “probably more than I need to.” No drug use.
FAMILY HISTORY: The patient’s father died of a brain aneurysm in his 50s. Mom had colon cancer in her 80s and also hypertension. Five older sisters all with hypertension and hypercholesterolemia. No known coronary artery disease.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: No fevers. Weight up 15 lbs since March. HEENT: Teeth doing okay. Does not feel congested in his sinuses. CARDIOVASCULAR: No chest pains, palpitations, PND, orthopnea or edema. RESPIRATORY: No shortness of breath. He does have a chronic intermittent cough that he has had for years. He had a chest x-ray a couple of years ago to evaluate this which was apparently normal. GI: No abdominal pain. No reflux-type symptoms. No change in bowel habits. GU: No hematuria or dysuria. MUSCULOSKELETAL: No chronic joint pains. PSYCHIATRIC: Not suicidal.
PHYSICAL EXAMINATION:
VITAL SIGNS: Weight 86.7 kg which is 191 lbs, blood pressure 174/114, pulse 103.
HEENT: Conjunctivae pink. Sclerae anicteric. Oropharynx clear.
NECK: No lymphadenopathy or thyromegaly or JVD.
LUNGS: Clear to auscultation and percussion.
HEART: Regular rate and rhythm without murmur, rub or gallop.
ABDOMEN: Normal bowel sounds. Soft, nontender. No hepatosplenomegaly.
EXTREMITIES: No cyanosis, clubbing or edema.
PSYCHIATRIC: Normal affect and behavior with seemingly good insight.
ASSESSMENT AND PLAN:
- Hypertension, poor control even with supposed white coat hypertension. He again is worried about side effect of his medications. We talked about many options and decided to change him to HCTA 25 mg a day and Norvasc 10 mg a day.
- Hypercholesterolemia. We will check lipid panel today. We will hold off on Lipitor for now, but will likely restart this once we confirm he is not having drug side effects. He is also interested in possibly trying fish oil.
- Psychiatric. He was not interested in counseling at all. He was interested in medication. We will start Celexa 20 mg a day. He will titrate this up to 40 mg after three to four weeks. He will call us in a few weeks if he is having any problems.
- Health maintenance. We will hold on PSA screening for a bit as he has been screened in the past. We will repeat colonoscopy in a few years and will try to get records of prior polyp pathology. He will try to focus on drinking a bit less alcohol and getting some regular exercise and eating better. Continue baby aspirin.
- Return to clinic in two months.
John Student, MS3
Seen with Joe Doctor, MD
