PREOPERATIVE DIAGNOSIS: Status post left dismembered pyeloplasty with stent placement.
POSTOPERATIVE DIAGNOSIS: Status post left dismembered pyeloplasty with stent placement.
PROCEDURES: Cystoscopy with left stent removal.
DESCRIPTION OF PROCEDURE: After obtaining informed consent, the patient was taken to the operative suite. Sedation was administered by Anesthesia. The patient was placed in the dorsal lithotomy position. Genitalia were prepped and draped in the usual fashion. A 10 cc of lidocaine jelly was instilled per urethra. A #22-French cystoscope was advanced per urethra. The bladder was visualized with #30 and #70-degree lenses with the findings as above. The stent was grasped with endoscopic forceps and removed. The stent was inspected and it was intact. The patient tolerated the procedure well without any apparent complications.
Answers : CPT-52310 , DX- V53.6, PX- 98.19.
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Answers : CPT-52281 , DX- 788.1, 618.01, PX- 58.5.
Answers : CPT-52310 , DX- V53.6, PX- 98.19.
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PREOPERATIVE DIAGNOSIS: Left lower pole renal stone.
POSTOPERATIVE DIAGNOSIS: Left lower pole renal stone.
PROCEDURE: Left ESWL.
ANESTHESIA: General.
ANESTHESIOLOGIST:
COMPLICATIONS: None.
INDICATIONS: Mr. Stapp is a 68-year-old white male with a 1 cm left lower pole stone. Options were discussed with the patient. He presents at this time for left ESWL.
DESCRIPTION OF PROCEDURE: After obtaining informed consent, the patient was taken to the procedure room, placed on the lithotripsy table in the supine position. The stone was then targeted using fluoroscopy. General anesthetic was administered by anesthesia. Starting at power level #1, 200 shocks delivered to the stone. This was increased to level #2 for 400 shocks, level #3 for 400 shocks, level #4 for 400 shocks, and level #5 for 2000 shocks for a total of 2500 shocks delivered to the stone. There appeared to be some fragmentation, but majority of the stone was still visible. The patient tolerated the procedure well without any apparent complications. He most likely will need a re-treatment.
Answers : CPT-50590 , DX- 592.0 , PX- 98.51.
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PREOPERATIVE DIAGNOSIS: Chronic dysuria.
POSTOPERATIVE DIAGNOSIS: Chronic dysuria.
PROCEDURE: Cystoscopy with urethral calibration.
FINDINGS: Urethra revealed no stenosis. Bladder revealed very mild cystocele, but no suspicious tumors or lesions seen. No urethral mass or diverticulum appreciated.
DETAILS OF PROCEDURE: After obtaining informed consent, the patient was taken to the procedure room. Sedation was administered by Anesthesia. The patient was placed in the dorsal lithotomy position. Genitalia were prepped and draped in the usual fashion. A 10 cc of lidocaine jelly was instilled per urethra. The urethral bougies were used to calibrate the urethra. It was calibrated with #26-French with no stenosis. A #22-French cystoscope was then advanced per urethra into the bladder. The bladder was visualized with #30 and #70-degree lenses with the findings as above. The scope was removed. The patient tolerated the procedure well without any apparent complications.
These findings were discussed with the patient and significant other. Recommended she see a gynecologist for possible vaginal causes for her chronic dysuria, which actually is more of a chronic burning even can occur without urination.
Answers : CPT-52281 , DX- 788.1, 618.01, PX- 58.5.
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