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Sample Medical Report 1 PREOPERATIVE DIAGNOSIS: Right laryngeal lesion. POSTOPERATIVE DIAGNOSIS: Right laryngeal lesion. PROCEDURE: Microsuspension laryngoscopy with excision of right laryngeal lesion. ANESTHESIA: General. ESTIMATED BLOOD LOSS: Minimal. SPECIMENS REMOVED: Right laryngeal lesions. COMPLICATIONS: None. INDICATIONS FOR SURGERY: The patient is an 84-year-old man with a history of dysphonia. He was found by … Read more
Medical Coding Example 1 EXAM: NM GASTRIC EMPTYING STUDY REASON FOR STUDY: Nausea and vomiting CLINICAL HISTORY: Nausea and vomiting TECHNIQUE: A standard meal consisting of Eggbeater 4 oz, toast, jam and water was labeled with the radiopharmaceutical and administered orally to the patient. Subsequent static images were obtained at approximately 60 minutes, 120 minutes, 180 and … Read more
Medical Coding Example Report 1 PREOPERATIVE DIAGNOSIS: Left small saphenous vein insufficiency with left lower extremity varicose veins that are symptomatic. POSTOPERATIVE DIAGNOSIS: Left small saphenous vein insufficiency with left lower extremity varicose veins that are symptomatic. PROCEDURE: Left small saphenous vein radiofrequency ablation. Phlebectomy of left lower extremity varicose veins with 6 incisions. … Read more
PREOPERATIVE DIAGNOSES: Rule out rotator cuff tear of the right shoulder.
POSTOPERATIVE DIAGNOSES: 1. Partial thickness tear of supraspinatus, right shoulder.
Type II superior labral tear, right shoulder.
Degenerative joint disease with chondral injury and multiple loose bodies intraarticularly, right shoulder.
OPERATIVE PROCEDURES:
ANESTHESIA: General endotracheal.
ESTIMATED BLOOD LOSS: Minimal.
DESCRIPTION OF PROCEDURE: