Reference no: EM133587058
ASSIGNMENT:
PROBLEM:
PREOPERATIVE DIAGNOSIS: Right supraglottic mass.
POSTOPERATIVE DIAGNOSIS: Right supraglottic mass.
INDICATIONS: is a 69-year-old lady with an extensive history of smoking. She developed progressive hoarseness and dysphagia and was assessed by myself in the clinic. She was found to have a right supraglottic mass on endoscopy. We have no imaging to compare this to. As such, it warranted a panendoscopy and biopsy of this lesion that was suspected to be cancer. She was counseled on the risks and benefits and chose to undertake surgery after signing informed consent. PROCEDURE: was met in the preoperative area. The plan for the procedure was reviewed. The consent was reviewed. She ate a small amount of yogurt in the morning, and as such, we had to postpone her surgery by 6 hours. She was eventually taken to the Operating Room and placed in the supine position on operative table. The operative team performed a time-out together. The patient was then put under general anesthetic without incident. She was then intubated with a 6 endotracheal tube with direct laryngoscopy with a suboptimal view but no complications.
The bed was turned 180 degrees. The patient was prepped and draped in a standard manner. The neck was palpated. The oral cavity was examined visually and palpation as was the oropharynx. The laryngoscope was then introduced in the oral cavity and used to visualize the larynx and suspend it. Once we achieved suspension, we used the telescope to directly examine the tumor. We then biopsied the tumor from the false vocal cord and the vallecula We sent two separate specimens. We mopped up any bleeding and decongested the vocal cords with topical adrenaline for numerous minutes. We then removed the pledgets. We then used the flexible bronchoscope to examine the glottis, subglottis and trachea and primary and secondary bronchi. Findings are described above. We ran aroUild the endotracheal tube coupler after it was deflated by the anesthesia team and reinflated it once we were done.
The flexible esophagoscope was used to retroflex around the soft palate and examine the nasopharynx. We then examined the hypopharynx, upper esophagus and lower esophagus with insufflation upon withdrawal of the esophagoscope. Once the esophagoscope and the direct laryngoscope were removed, patient care was turned to the Anesthesia Team who reversed the anesthetic and brought the patient to the Postop Anesthetic Recovery Room in standard stable condition. All sponge and instrument counts were correct at the end of the procedure.
Procedure: Flexible Laryngoscopy Pre-procedure Diagnosis: Dysphagia,? BOT Mass Post-procedure Diagnosis: Dysphagia, Supraglottic Mass Procedure Details: Page 5 of 6 The procedure and its benefits and risks were explained to the patient. Informed consent was obtained. The patient was placed in the sitting position. After topical anesthesia and decongestion, a flexible nasopharyngoscope was passed into the nasal cavity. The nasal cavities, nasopharynx, oropharynx, hypopharynx, and larynx were all examined. Vocal cords were examined during respiration and phonation. The scope was then carefully removed. The patient tolerated the procedure well.
NEED HELP WITH:
- What is the root operation for both of the biopsy procedures?
- What is the PCS procedure code for the scope with vocal cord bx?
- What is the PCS procedure code for the scope with epiglottis bx?
- What is the root operation for both of the scope procedures?
- What is the PCS procedure code for the bronchoscopy?
- What is the PCS procedure code for the esophagoscopy?