M132 Module 08 Coding Assignment

M132 Module 08 Coding Assignment essay assignment

M132 Module 08 Coding Assignment essay assignment

1. A 37 weeks intrauterine pregnancy.

2. Previous cesarean section with rupture of membranes.

 

POSTOPERATIVE DIAGNOSES:

1. A 37 plus weeks gestation.

2. Previous cesarean section with spontaneous rupture of membranes.

3. Pelvic adhesions.

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ANESTHESIA: Spinal.

 

PROCEDURE PERFORMED: Repeat low-transverse cesarean section.

 

FINDINGS: Male infant, 6 pounds, 5 ounces. Apgars 9 and 9.

 

ESTIMATED BLOOD LOSS: 800 mL.

 

The patient’s condition after surgery, the patient tolerated the procedure well.

 

PERTINENT HISTORY AND PHYSICAL: The patient is a 20-year-old black female, gravida 2, para 1-0-0-1, last normal menstrual period 08/02/2006, EDC 05/08/2007, 37-5/7th weeks gestation, she presented to L D with spontaneous rupture of membranes, history of previous cesarean section in 2009 for CPD.

 

PAST MEDICAL HISTORY: She denies allergies.

 

MEDICATIONS: She is on prenatal vitamins.

 

MEDICAL SURGICAL: She denies any significant history except for C-section in 2006.

 

SOCIAL HISTORY: She denies ethanol, tobacco, or drugs.

 

PSYCHIATRIC HISTORY: Noncontributory.

 

FAMILY HISTORY: Noncontributory.

 

PHYSICAL EXAMINATION: Vital Signs: Temperature, the patient is afebrile, pulse 94, respiratory rate 20, BP 97/50, fetal heart tone was 140 to 145. HEENT was within normal limits. Neck is supple. Chest: Cardiovascular, Sl and S2 regular without gallop or murmur. Lungs: Clear both fields. Breasts: No masses or tenderness. Abdomen: Gravid. Pelvic: Cervix was 50% effaced, 1 to 2 cm dilated, presenting part was vertex at -2 station, there was gross fluid, clear and Nitrazine was positive. The patient was therefore taken to the operating room for a repeat low-transverse cesarean section.

 

OPERATIONAL TECHNIQUE: The patient was brought to the operating room and under spinal anesthesia, was prepped and draped in the usual manner for a gynecologic abdominal operation. Through the old suprapubic Pfannenstiel skin incision, the abdominal cavity was entered into after much difficulty because of the pelvic abdominal adhesion. Following entry into the abdominal cavity, the bladder peritoneum was identified, reflected down. Following that, a midline low-transverse incision was made at the lower uterine segment with a knife and carried down into the uterine cavity without any difficulty. The incision was then extended to the level of the round ligament on both sides. Following which a male infant in vertex position was delivered with vacuum and handed over to the nursery staff in attendance. Birth weight was 6 pounds 5 ounces. Apgar was 9 and 9. Placenta was manually delivered. After remnants of the placental membranes have been removed from the uterine cavity, the uterine cavity was then closed with #1 chromic continuous interlocking suture. Hemostasis was verified and found to be adequate. The ovaries and tubes were inspected and found to be within normal limits. The abdominal cavity was copiously irrigated. The abdominal cavity was then closed in layers. The pyramidal muscle was closed with 2-0 interrupted suture, the fascia was closed with #1 Vicryl continuous suture in two halves and the skin was closed with staples. The patient tolerated the procedure well and left the operating room, awake, conscious, and in excellent condition.