#3 Medical/Billing code for Bilateral breast augmentation with silicone implants, open, cosmetic

Mrs. Tom, a 79 year old female presents to the ER with complaints of a persistent productive cough, fatigue, fever and shortness of breath. Mrs. Tom reports that she has had a persistent cough and shortness of breath with activity for several months.  She was given a prescription for antibiotics for a presumed infection 4 weeks ago, with only slight improvement in symptoms.  Her past medical history includes stroke 6 months ago.  She also smokes 20 cigarettes per day.  On exam, she has a fever with decreased lung sounds bilaterally to auscultation with the right side slightly more obvious than the left.  She is obviously short of breath and presents with 4-word dyspnea.  Her vital signs are BP 110/70, HR 99, SP02 94% on 4 L of oxygen via nasal prongs, Temp 38.9

Mrs. Tom, a 79 year old female presents to the ER with complaints of a persistent productive cough, fatigue, fever and shortness of breath. Mrs. Tom reports that she has had a persistent cough and shortness of breath with activity for several months. She was given a prescription for antibiotics for a presumed infection 4 weeks ago, with only slight improvement in symptoms. Her past medical history includes stroke 6 months ago. She also smokes 20 cigarettes per day. On exam, she has a fever with decreased lung sounds bilaterally to auscultation with the right side slightly more obvious than the left. She is obviously short of breath and presents with 4-word dyspnea. Her vital signs are BP 110/70, HR 99, SP02 94% on 4 L of oxygen via nasal prongs, Temp 38.9.

1. Identify the infection of inflammatory response that Mrs. Tom is experiencing? (2)

2. Explain the pathology of how smoking affects the innate defense system of the lungs? (5)

3. What diagnostic tools could you expect to be used in this case? (xray,CT,laboratory data etc). (2)

4. Identify risk factors that Mrs. Tom has that are associated with the diagnosis? (3)

5. Internal medicine assesses Mrs. Tom and orders a STAT lactate and arterial blood gasses. Based on the patient’s vital signs above, what would you expect to see in the results of these tests? (5)

What procedure(s) will you need to code? (Check all that apply.)

Documentation:

PREOPERATIVE DIAGNOSIS: Mass of lung

POSTOPERATIVE DIAGNOSIS: Carcinoma of the right lung

OPERATION PERFORMED: Bronchoscopy and right upper lobectomy

The patient was brought into the operating room, and after the

administration of anesthesia, the patient was prepped and draped in the usual sterile fashion. The patient was placed in the left lateral decubitus position. A thoracotomy incision was made. This exposed the chest muscles, which were incised and retracted. The fourth and fifth ribs were visualized and transected to allow entrance to the chest. A tumor mass was noted. This mass measured 7.0 cm in diameter, involving the right lung pper lobe. The mass was excised in its entirety, and a biopsy of the mass vas taken and sent for frozen section. The frozen section revealed quamous cell carcinoma. Nodes were then dissected around the pulmonary artery and the trachea. The nodes were sent for frozen section. The nodes were identified as negative per pathology. Saline was irrigated into the chest. It was noted that the liver and diaphragm appeared to be normal with

no lesions seen. After verification that the sponge count was correct, chest tubes were placed for drainage. The surgical wound was closed in layers with chromic catgut and nylon. The patient tolerated this portion of the procedure well The patient was then placed in the supine position for the bronchoscopy.

The patient was still under anesthesia. A flexible fiberoptic bronchoscope was inserted. Patient bronchi were noted bilaterally. The scope was withdrawn. The patient was awakened and sent to the recovery area in stable condition.

a. Bronchoscopy

b. Lobectomy

c. Excision

d. Biopsy