Case Study 1 Operative Report PREOPERATIVE DIAGNOSIS:Right..

Case Study 1 Operative Report PREOPERATIVE DIAGNOSIS:Right…  Case Study 1Operative Report PREOPERATIVE DIAGNOSIS: Right bimalleolar fracture;    Right proximal humeral shaft fracture  POSTOPERATIVE DIAGNOSIS: Same  PROCEDURE:      ORIF, right bimalleolar fracture Splinting, right proximal humeral shaft fracture  DESCRIPTION: Under general anesthesia, the patient’s right ankle was prepped and draped in sterile fashion. We then made a small incision over her lateral malleolus in line with her distal fibula. We then carefully dissected down to the fracture site. It was noted that the epiphysis was displaced posteriorly, as well as shortened slightly. The fracture site was irrigated and we performed a reduction. We had to free up the back of the periosteum in order to swing the epiphysis underneath the shaft and metaphysis. A clamp was placed to hold the reduction. X-rays were obtained. AP mortise and lateral x-rays, which did show good overall reduction. We then placed a 0.062 inch Steinmann pin through the epiphysis through the fracture site and then into the shaft of the fibula. We were able to get very good purchase with this, and it was very stable.  We then moved to the medial malleolus of the tibia and made a small incision again over the fracture site. We then got down to the fracture site which was irrigated. We reduced the fracture and pushed on the bottom aspect of the medial malleolus. We checked anteromedially and then around the fracture site to ensure good reduction. We then placed a 0.062 inch K wire off the tip of the medial malleolus, through the fracture site, and through the physis, gaining purchase through the cortex of the metaphysis. We then placed another K wire 0.062 inch Steinmann pin just posterior to gain 2 pin fixation. Xrays were then obtained to ensure our reduction was anatomic. Incisions were irrigated. We used 3-0 Vicryl suture in the subcutaneous tissues and then a 4-0 running Monocryl suture through the skin. Steri-Strips were then placed over the top. The pins were cut and bent at the skin, and Betadine goop with felt pad was placed over the pin sites. We then placed her in a well-padded, well molded long-leg cast. X-rays were obtained before and after casting, which did show overall good axial alignment on both AP and lateral projections as well.  We then obtained x-rays of her right proximal humeral shaft fracture, which did show very good alignment with a small amount of varus and a small amount of apex posterior angulation, without any loss of reduction. She was placed her into a wrapped splint and back into her sling. No formal reduction was performed. She was awakened and transferred to PACU in stable condition. The patient will be admitted to the hospital for pain control. She will be given IV pain medications and transitioned to oral pain medications. She will be non-weightbearing to the right lower extremity, as well as right upper extremity 1. WHAT IS THE OBJECTIVE OF PROCEDURE2. ASSIGN  2 ICD CM CODES- Diagnosis codes 23 ASSIGN 3  ICD PCS CODES4.Coding guideline or coding notes for diagnosis- 5 Coding guidelines for procedureHealth Science Science Nursing BIOLOGY 159

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