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OPERATIVE REPORT PREOPERATIVE DIAGNOSIS: 1 Hypoxia. 2 Pneumothorax. POSTOPERATIVE DIAGNOSIS: 1 Hypox

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OPERATIVE REPORT PREOPERATIVE DIAGNOSIS:

1 Hypoxia.

2 Pneumothorax.

POSTOPERATIVE DIAGNOSIS:

1 Hypoxia.

2 Pneumothorax.

PROCEDURE: Chest tube placement.

DESCRIPTION OF PROCEDURE: The patient was previously sedated with Versed and paralyzed with Nimbex. Lidocaine was used to numb the incision area in the midlateral left chest at about nipple level. After the lidocaine, an incision was made, and we bluntly dissected to the area of the pleural space, making sure we were superior to the rib. On entrance to the pleural space, there was immediate release of air noted. An 18-gauge chest tube was subsequently placed and sutured to the skin. There were no complications for the procedure, and blood loss was minimal.

DISPOSITION: Follow-up, single-view, chest x-ray showed significant resolution of the pneumothorax except for a small apical pneumothorax that was noted.

A. 32551, 71045, R09.02, J93.9

B. 32556, R09.02, J93.0

C. 32551, J93.9, R09:02

D. 32556, R09.02, J93.9

SCIENCE
HEALTH SCIENCE
NURSING
CODING HIT215

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