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Pre-op Diagnosis: Morbid obesity (CMS/HCC) [E66.01] Body mass index is 43.75 kg/m². Essential hypertension, OSA with cpap Post-op Diagnosis: Same as Pre-op Procedure(s):  Procedure(s): SLEEVE GASTRECTOMY ROBOTIC ASSISTED Proc. Description(s) & CPT Code(s): SLEEVE GASTRECTOMY ROBOTIC ASSISTED:  Anesthesia: General Estimated Blood Loss: None Quantitative Blood Loss: No data recorded   Drain: None  Complications: none Findings: Liver appeared fatty Technique:  Tonie Williams is electively admitted for robotic sleeve gastrectomy today … Read more

Pre-op Diagnosis: Chronic pain syndrome [G89.4] Mechanical breakdown of implanted electronic neurostimulator of spinal cord, initial encounter (CMS/HCC) [T85.112A]    Post-op Diagnosis: Same as Pre-op Procedure(s): Spinal Cord Stimulator Battery Replacement – Wound Class: Clean Anesthesia: Monitor Anesthesia Care Estimated Blood Loss: None Drain:  None   Total IV Fluids:  Per anesthesia record   Specimens: No specimens Complications:  None Findings:  None      Disposition: aroused from sedation, and taken to … Read more

Pre-op Diagnosis: Arthritis of left shoulder region [M19.012] Left shoulder rotator cuff tear arthropathy and severe degenerative changes at the level of the glenohumeral joint with inferior humeral head osteophyte formation. Post-op Diagnosis: Same as Pre-op Procedure(s):  Left – LEFT REVERSE TOTAL SHOULDER ARTHROPLASTY Anesthesia: General and interscalene regional nerve block. Estimated Blood Loss: 200 mL Specimens:  Standard arthroplasty specimens. Implants: DJO reverse total shoulder … Read more

Pre-op Diagnosis: Uric acid nephrolithiasis [N20.0] Post-op Diagnosis: Left nephrolithiasis Procedure(s):  Left – URETEROSCOPY – Wound Class: Clean Contaminated  – Incision Closure: No Incision / NA Left – CYSTOSCOPY LITHOTRIPSY URETERAL and renal STONEs – Wound Class: Clean Contaminated  – Incision Closure: No Incision / NA Left – CYSTOSCOPY, URETERAL STENT EXCHANGE – Wound Class: Clean Contaminated  – Incision Closure: No … Read more

Pre-op Diagnosis: Excess skin [L98.7] Post-op Diagnosis: excess skin of upper arms ( bat wing deformity) bilateral Excess skin of chest wall right and left lateral chest35x10 cm, 38×12 cm right chest Painful scar abdomen 21 cm horizontal scar and 19 cm vertical component Procedure(s):  Bilateral – BRACHIOPLASTY excision bilateral excess soft tissue lateral chest Right 38×12 cm … Read more

Pre-op Diagnosis: Bilateral ovarian cysts [N83.201, N83.202] Post-op Diagnosis: Same as Pre-op s/p procedure performed Procedure(s):  OVARIAN CYSTECTOMY ROBOTIC ASSISTED/ ROBOTIC ASSISTED UNILATERAL OVARIAN  CYSTECTOMY, POSSIBLE UNILATERAL SALPINGOOOPHORECTOMY SALPINGOOPHORECTOMY BILATERAL ROBOTIC ASSISTED/ POSSIBLE UNILATERAL Anesthesia: General Complications: none Findings: Normal appearing female external genitalia On laparoscopic entry, uterus and right ovary normal appearing. Left ovary with an approximately 3 cm hardened … Read more

PREOPERATIVE DIAGNOSIS: 1. Left shoulder Rotator cuff tear. 2. Subacromial bursitis.  3.  Subacromial impingement. 4.  Acromioclavicular arthritis.  5. Biceps tendon tear. POSTOPERATIVE DIAGNOSIS: 1. Same PROCEDURE: 1. Left shoulder arthroscopic rotator cuff repair.with soft tissue augmentation. 2. Subacromial decompression/acromioplasty. 3. Arthroscopic debridement of subacromial space and glenohumeral joint.  4.  Arthroscopic distal clavicle excision/Mumford procedure. 5. Mini-open subpectoral biceps tenodesis.  ANESTHESIA GIVEN: General with interscalene block PREOPERATIVE … Read more

Pre-op Diagnosis: Renal stones, Recurrent UTI, solitary Left Kidney  Post-op Diagnosis: Same, Bladder lesion overlying bladder neck and LEFT Ureteral orfice Proc. Description(s) & CPT Code(s): LEFT URETEROSCOPIC LITHO, STONE EXTRACTION: BLADDER BIOPSY; URETEROSCOPY CYSTOSCOPY WITH STENT PLACEMENT:  Anesthesia: General Complications: none Findings: 1.  Stones mostly matrix material with small pebble like consistency. Removed with prolonged basketing and irrigation.  Papillary … Read more

PREOPERATIVE DIAGNOSIS: Right shoulder rotator cuff tear. Right shoulder SLAP tear. Right shoulder impingement. Right shoulder AC DJD. POSTOPERATIVE DIAGNOSIS: Right shoulder rotator cuff tear. Right shoulder SLAP tear. Right shoulder impingement. Right shoulder AC DJD. Right shoulder biceps tear INDICATION FOR PROCEDURE: Brief History:  A 76 y.o. -year-old male  has had persistent shoulder pain and functional limitation despite conservative management.  MRI showed above-mentioned findings.  Operative and … Read more