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SUBJECT: HIM 205 CHART AUDITING 

 

 

AUDIT REPORT T7.1 OPERATIVE REPORT, APPENDECTOMY

LOCATION: Inpatient, Hospital

PATIENT: Rachel Wiggins

ATTENDING PHYSICIAN: Leslie Alanda, MD

PREOPERATIVE DIAGNOSIS: Abdominal pain with acute appendicitis

POSTOPERATIVE DIAGNOSIS: Acute appendicitis

ANESTHESIA: General

INDICATIONS: Rachel is a 17-year-old female who has a history and exam consistent with acute appendicitis. Her diagnosis as well as the recommended procedure of an appendectomy was discussed with the patient and her parents.We discussed the other possible diagnoses that could be present. We discussed that some of these are treated medically and some are treated operatively. I would recommend an appendectomy as this is quite suspicious that she indeed has appendicitis.We discussed potential problems with a perforated appendicitis. This is also possible that this has occurred even at this point. I discussed if her appendix appears to be grossly normal that we will still plan to remove her appendix at the time of the operation and then look for other causes of her abdominal pain.
If something needs to be done surgically, we will go ahead and proceed with it even if it requires a larger incision or a completely different incision to manage this.We discussed the risk of bleeding and infection.We discussed injury to intestines and other intra-abdominal structures.We discussed wound infections and abscesses that can occur. Her questions were answered. She understands and wishes to proceed with an appendectomy.

PROCEDURE: Rachel was then brought to the operating room and placed in a supine position on the table. After receiving a general anesthetic, she was prepped and draped in a sterile fashion. Incision line was marked out in the right lower quadrant. This was just a little bit above McBurney’s point. This was infiltrated with 0.5% Marcaine. We waited a couple of minutes. Incision was then made and carried down through Scarpa’s down through the subcutaneous tissues down to the anterior fascia. The anterior fascia was sharply divided. Muscle-splitting incision was carried out down to the peritoneum. This was grasped in a three-step technique, and the peritoneal cavity was entered sharply. The inflamed appendix was identified and brought out through the wound. This did appear to be grossly inflamed, especially the distal aspect of this. It appeared to be fairly early on. The mesoappendix was taken down between clamps, transected, and ligated with 3-0 Vicryl in continuity. The origin of this appendix was then crushed and clamp was moved just distal to this. No Vicryl was used to ligate the origin of the appendix. The appendix was then transected sharply and handed off the table as a specimen. The appendiceal stump was cauterized. A 3-0 silk pursestring suture was placed in the base of the cecum. This was used then to imbricate the appendiceal stump. We also used a Z-stitch of 3-0 silk over this to further “roll this in.” Hemostasis was present. This was then returned to the peritoneal cavity. The right lower quadrant and the pelvis were irrigated out with warm normal saline. Clear returns were established. The posterior fascia and peritoneum were closed with a 0 Vicryl in a running fashion. The wound was irrigated out. 0 Vicryl was used to approximate the internal obliques in interrupted fashion. Wound was irrigated out. The anterior fascia was closed then with interrupted sutures of 0 Vicryl in a figure-of-eight fashion. The wound was irrigated out. Skin was closed with a 4-0 Vicryl in a subcuticular fashion. Steri-Strips and sterile dressings of Telfa and Tegaderm were applied. The patient tolerated the procedure well and went to the recovery room in stable condition.

PATHOLOGY REPORT LATER INDICATED: Acute suppurativa appendix

T7.1:
SERVICE CODE(S): 44960, 49084-51
ICD-10-CM DX CODE(S): K37, R10.9
INCORRECT/MISSING CODE(S):

SCIENCE
HEALTH SCIENCE
NURSING
CMA – HIMBC MED 107