LOCATION: Outpatient, Hospital
PATIENT: Kaitlyn Carlton SURGEON: Loren White, M.D.
ANESTHESIA: CRNA is Karen Demers
PREOPERATIVE DIAGNOSIS:
Epiphora, both eyes
Nasolacrimal duct obstruction, both eyes
POSTOPERATIVE DIAGNOSIS: Same.
PROCEDURE PERFORMED: Nasolacrimal duct probing, both eyes
ANESTHESIA: General
INDICATIONS: This healthy 3-year-old toddler was referred after an allergy workup to investigate her chronic otitis media, PE tubes times two, and the chronic epiphora that she has had in both eyes. The mother was counselled as to the success of probing at this age and the possible reoperations that may be needed.
PROCEDURE: After the patient was placed under suitable anesthesia via the mask, a small punctum dilator was used to dilate the punctum inferiorly and superiorly. These were found to be very tight and occluded. A 2-0 Bowman probe could be passed only through the inferior system with difficulty on both sides. The C-loop was not irrigatable. Probing could not be attempted because there was a large bony obstruction that resisted all efforts to pass the tube. There was no fluorescein inserted in the nose. TobraDex drops were placed in the eyes. The procedure was complete, and the patient was sent to the recovery room. There were no complications.
The anesthesia service is for a nasolacrimal duct
probing. The lacrimal duct is considered the adenxa of the eye
reported with _____. The CRNA was working without medical
direction; therefore, modifier –___ (CRNA without medical
direction) is appended to _____. Physical status modifier -___
reports a normal healthy patient.
68810 nasolacrimal probing
CRNA without medical direction QZ
P1 repots normal healthy patient
LOCATION: Outpatient, Hospital PATIENT: Kaitlyn Carlton SURGEON: Loren White, M.D. ANESTHESIA: CRNA is Karen Demers PREOPERATIVE...
LOCATION: Inpatient, Hospital PATIENT: Thomas Wilder PHYSICIAN: Loren White, M.D. ANESTHESIOLOGIST: CRNA is Karen Demers PREOPERATIVE DIAGNOSIS: 25% body surface area burns on face, posterior neck, trunk, bilateral upper extremities, hands, left foot and ankle. The total body surface area addressed was 15% which were third degree burns. POSTOPERATIVE DIAGNOSIS: Same. PROCEDURES: 1. Split-thickness skin graft, left upper back 14 x 6 cm. 2. Sheath split-thickness skin graft, left ankle 6 x 2 cm. ANESTHESIA: General. INDICATIONS: This 3-year-old was...
LOCATION: Inpatient, Hospital PATIENT: Thomas Wilder PHYSICIAN: Loren White, M.D. ANESTHESIOLOGIST: CRNA is Karen Demers PREOPERATIVE DIAGNOSIS: 25% body surface area burns on face, posterior neck, trunk, bilateral upper extremities, hands, left foot and ankle. The total body surface area addressed was 15% which were third degree burns. POSTOPERATIVE DIAGNOSIS: Same. PROCEDURES: 1. Split-thickness skin graft, left upper back 14 x 6 cm. 2. Sheath split-thickness skin graft, left ankle 6 x 2 cm. ANESTHESIA: General. INDICATIONS: This 3-year-old was...
LOCATION: Inpatient, Hospital PATIENT: Charlene Tipton SURGEON: Loren White, M.D. PRE/POSTOPERATIVE DIAGNOSIS: Right breast mass. PROCEDURE(S) PERFORMED: Right breast open biopsy. ANESTHESIA: General endotracheal. INDICATIONS: Charlene is a 66-year-old female who presented with a palpable right breast mass. A biopsy was done which showed atypical cells and was felt to be suspicious for cancer. She also had a highly suspicious lesion on ultrasound in the same area. An open biopsy was recommended. Possible definitive treatment with simple mastectomy was also...
LOCATION: Outpatient, Hospital PATIENT: Fanny Wilder SURGEON: John Hodgson, M.D. PREOPERATIVE DIAGNOSIS: Left carpal tunnel syndrome. POSTOPERATIVE DIAGNOSIS: Same. PROCEDURE PERFORMED: Carpal tunnel released, left wrist. ANESTHESIA: Regional. INDICATIONS: Patient has long history of numbness, tingling and pain from the wrist into the thumb of the left hand. Patient has used immobilizer with minimal effectiveness. Risks and benefits were discussed, she is aware of possible reoccurrence of symptoms. The procedure was explained and her questions were answered and she elects...
LOCATION: Outpatient, Hospital PATIENT: Shelby Winston SURGEON: Larry P. Friendly, M.D. PREOPERATIVE DIAGNOSIS: Recurrent right inguinal hernia. POSTOPERATIVE DIAGNOSIS: Same. PROCEDURES PERFORMED: Repair of recurrent right inguinal hernia. HISTORY: This is an 80-year-old female who has previously undergone a right inguinal hernia repair performed earlier this year. The repair was a type repair, and she, subsequently, returned with complaints of a new bulge in the right groin. An ultrasound was performed which demonstrated evidence of a right inguinal hernia. She...
LOCATION: Inpatient, Hospital PATIENT: SURGEON: PREOPERATIVE.DIAGNOSES: 1. Septal deviation. 2. Bilateral sinonasal polyposis. 3. Pansinusitis, chronic 4. Bilateral inferior turbinate hypertrophy. 5. Nasal obstruction. POSTOPERATIVE DIAGNOSIS: Same. PROCEDURE PERFORMED: 1.Bilateral endoscopic total ethmoidectomy. 2. Bilateral endoscopic maxillary antrostomy with removal of polyps from maxillary sinus. 3. Bilateral endoscopic sphenoidotomy. 4. Septoplasty. 5. Bilateral inferior turbinate overfracture. ANESTHESIA: Endotracheal. INDICATIONS: A 43-year-old male with history of nasal trauma that resulted in a septal deviation. He also has a history of bilateral...