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what are the medical codes for SEX: MALE Age: 27 DATE OF OPERATION: 01/1/20XX PREOPERATIVE DIAGNOSIS: LEFT BOTH BONE FOREARM OPEN FRACTURE DISPLACED COMMINUTED DUE TO GUNSHOT WOUND ULNA AND RADIUS SHAFTS TYPE III PROCEDURES: LEFT FOREARM INTRAMEDULLARY NAILING WITH ACUMED INTRAMEDULLARY NAILS, REPEAT IRRIGATION OF GUNSHOT WOUNDS POSTOPERATIVE DIAGNOSIS: LEFT BOTH BONE FOREARM OPEN FRACTURE DISPLACED COMMINUTED DUE TO GUNSHOT WOUND ULNA AND RADIUS SHAFTS TYPE III SURGEON: ANESTHESIA: GENERAL, ENDOTRACHEAL TUBE. ESTIMATE BLOOD LOSS: 10 CC. TOURNIQUET TIME: 60 MINUTES. ANTIBIOTICS: ANCEF 1 GM. COMPLICATIONS: NONE. INDICATIONS: The patient is a male who sustained gunshot wounds to the abdomen and the left forearm and he was stabilized by general surgery (ulna and radius shaft fractured) Options, risks and benefits were discussed with the patient and his father and they agreed with the internal fixation. I recommend an intramedullary rod due to the comminution and the probability of poor fixation with plating on the radius. PROCEDURE: The patient was brought to the operating room and anesthesia was induced via endotracheal tube. The left upper extremity was prepped and draped in sterile fashion. It was elevated, and the tourniquet was inflated to 250. A longitudinal incision was made over the
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HEALTH SCIENCE
NURSING

 
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