What are the principal diagnosis and the secondary diagnoses

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Reference no: EM133295642

Case: A 2-week-old male infant was admitted to the University Medical Center pediatric gastroenterology unit after being seen in the gastroenterology clinic. The infant was full-term when born and fed well after birth but then experienced occasional regurgitation of feedings. Several days later, the vomiting became more frequent and projectile, containing the previous feedings.

Shortly after the vomiting, the infant is ready to feed again. The parents were provided information about the child's condition and agreed to surgical correction of the digestive problem.

The operative report is as follows:

PREOPERATIVE DIAGNOSIS: Hypertrophic pyloric stenosis

POSTOPERATIVE DIAGNOSIS: Hypertrophic pyloric stenosis

PROCEDURE: Laparoscopic Pyloromyotomyvod

INDICATIONS: The infant is a 2-week-old male with hypertrophic pyloric stenosis diagnosed based on his history, physical findings and radiographic studies. The patient had metabolic derangements corrected before surgery that was consented to by the parents after receiving full disclosure of the potential risks versus benefits of the procedure.

FINDINGS: The upper abdomen was evaluated and appears normal. There was a hypertrophied pylorus. After the myotomy, no bile staining was found. The stomach was insufflated with air and no bubbles were observed at the myotomy site. The stomach was decompressedprior to the laparoscope's removal.

PROCEDURE: The patient was brought to the operating room and carefully placed and secured on the operating table. A time-out was performed to identify the patient, the diagnosis and the procedure, and anatomical site of the operation to be performed. General anesthesia induction and intubation were performed atraumatically. The stomach was decompressed with suction prior to intubation. Intravenous antibiotics were started. The abdomen was prepped and draped in standard laparoscopic procedure fashion. Marcaine local anesthesia was used at all incision sites. The umbilicus was cleaned with betadine and inverted. The hemostatic forceps was used to spread through the umbilical cicatrix. A 3mm port was introduced and the abdomen insufflated. The vision instrument was inserted and the pylorus was identified. Two incisions were made for the instruments to be inserted in the right upper quadrant lateral to the rectus muscle and the second instrument contralateral to that. The pyloric grasper instrument was placed through the right upper quadrant incision. The electrocautery instrument was inserted through the left upper quadrant incision. The pylorus was grasped and the electrocautery blade was used to incise the serosa. After that, the pyloric spreader was inserted and the pylorus muscle was divided along the length of it to the base of the submucosa. The duodenum was gently clamped and the stomach insufflated with the in-place OG tube. There was no bile leaking or air bubbles noted at the myotomy site. The stomach was decompressed prior to the removal of the instruments. No bleeding was noted from the incisions internally. The optic instrument was removed. The port was removed. The umbilicus opening was closed with 4-0 Vicryl sutures. The upper quadrant skin incisions were closed with 5-0 Monocryl sutures. The wounds were dressed and the patient was extubated and taken to the post anesthesia recovery unit in good condition.

Using ICD-10-CM, what are the principal diagnosis and the secondary diagnoses?

Reference no: EM133295642

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