Homework answers / question archive / WESTWARD HOSPITAL591 Chester RoadMasters, FL 33955RADIOLOGIST REPORT PATIENT: DATE OF ADMISSION: GRIFFTH, KERRAN  08/19/18 DATE OF DISCHARGE: 08/23/18 PREOP DIAGNOSIS: Right ureteral obstruction secondary to colon cancer POSTOP DIAGNOSIS: Right ureteral obstruction secondary to colon cancer SURGEON: Roger Abernathy, MD ANESTHESIA: General   Operation: 1

WESTWARD HOSPITAL591 Chester RoadMasters, FL 33955RADIOLOGIST REPORT PATIENT: DATE OF ADMISSION: GRIFFTH, KERRAN  08/19/18 DATE OF DISCHARGE: 08/23/18 PREOP DIAGNOSIS: Right ureteral obstruction secondary to colon cancer POSTOP DIAGNOSIS: Right ureteral obstruction secondary to colon cancer SURGEON: Roger Abernathy, MD ANESTHESIA: General   Operation: 1

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WESTWARD HOSPITAL591 Chester RoadMasters, FL 33955RADIOLOGIST REPORT PATIENT: DATE OF ADMISSION:

GRIFFTH, KERRAN

 08/19/18

DATE OF DISCHARGE: 08/23/18

PREOP DIAGNOSIS: Right ureteral obstruction secondary to colon cancer

POSTOP DIAGNOSIS: Right ureteral obstruction secondary to colon cancer

SURGEON: Roger Abernathy, MD

ANESTHESIA: General

 

Operation:

1. Cystoscopy

2. Right retrograde pyelogram with low Osmolar contrast material

3. Removal and replacement of double-J stent

 

HISTORY/INDICATIONS: This is a 32-year-old female with a history of colon cancer of the cecum and secondary right ureteral obstruction who had a stent inserted a number of months ago. At this time, she is in the hospital and it is time for a stent change. Consequently, the patient presents for the procedure.

 

PROCEDURE: The patient was taken to the operating room and there she was given general anesthetic, positioned in the dorsal lithotomy position, and the genitalia scrubbed and prepped with Betadine. Sterile towels and sheets were utilized to drape the patient in the usual fashion. A cystoscope was introduced into the bladder. The ureteral catheter was identified. It was grabbed and removed without any difficulty. Subsequently, the cystoscope was reinserted into the bladder and the right ureteral orifice was identified over a Pollack catheter. A glide wire was inserted into the right collecting system. Some contrast was injected and a hydronephrotic right side was noted. Then, the wire was placed through the Pollack catheter. With the wire in position, over the wire a 7 French 26 cm double-J stent was inserted. Excellent coiling was noted fluoroscopically in the kidney and distally with a cystoscope. The bladder was then drained and again it was inspected prior to removal. There was no evidence of any tumors or lesions in the bladder. The stent was in good position. The cystoscope was removed and the patient was taken to the recovery room awake and in stable condition.

 

Roger Abernathy, MD

 

556848/mt98328: 08/23/18 09:50:16 T: 08/23/18 12:55:01

 

 

Be sure to list the codes, one code per box, in the correct order, from top to bottom. Capitalization, punctuation, and spacing can impact whether or not your answer is correct. Follow coding best practices.

 

Determine the most accurate ICD-10-PCS code(s).