Coding Application Report
Coding Applications
The following Coding Application statements are intended to familiarize you with the coding process in a more concentrated and definitive manner. Please feel free to share with your instructor and with your fellow students your findings and methods. If you have questions this is the time to ask for clarity and explore the outcomes.
Review the ten Coding Application statements below and provide the answer for each problem as instructed. To print and review the problems before completing the Test click here.
To submit your answers, click on Tests in the left menu then Week 2 - Coding Applications Test.
PREOPERATIVE DIAGNOSIS: Lesion of vocal cords.
POSTOPERATIVE DIAGNOSIS: Tumor of left vocal cord.
OPERATION …show more content…
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 involving the right lung upper lobe. The right upper lobe was then removed. 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 …show more content…
It looks like she had some difficulty with sleep maintenance. She had sleep onset at 18.5 minutes, REM latency 171.5 minutes, again a little bit prolonged.
She had 27 respiratory events through the night, a mixture of obstructive apneas and obstructive hypopneas with a respiratory disturbance index of 5.1. Anything over 5 is considered significant. The longest duration of anyone event was 34 seconds. O2 sat was between 76 and 95%, with 29% of the time spent with O2 sats less than 88%. Heart rate varied between 55 and 113, somewhat varying with the obstructive events. The patient had grade 1-2 snoring noted, and respiratory disturbance events were most evident in REM while supine. All five stages of sleep were represented. Basically the only thing abnormal was a reduced amount of REM.
OVERALL IMPRESSION: This patient has significant obstructive sleep apnea based on the respiratory disturbance index of 5.1. which anything over 5 is considered significant, plus the amount of time that the patient spent hypoxic, at less than 88%. 29% of the time was spent that way. So I suspect that the patient does have significant obstructive sleep apnea. We will need a second sitting to do the CPAP titration.
The overall impression is obstructive sleep
The following Coding Application statements are intended to familiarize you with the coding process in a more concentrated and definitive manner. Please feel free to share with your instructor and with your fellow students your findings and methods. If you have questions this is the time to ask for clarity and explore the outcomes.
Review the ten Coding Application statements below and provide the answer for each problem as instructed. To print and review the problems before completing the Test click here.
To submit your answers, click on Tests in the left menu then Week 2 - Coding Applications Test.
PREOPERATIVE DIAGNOSIS: Lesion of vocal cords.
POSTOPERATIVE DIAGNOSIS: Tumor of left vocal cord.
OPERATION …show more content…
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 involving the right lung upper lobe. The right upper lobe was then removed. 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 …show more content…
It looks like she had some difficulty with sleep maintenance. She had sleep onset at 18.5 minutes, REM latency 171.5 minutes, again a little bit prolonged.
She had 27 respiratory events through the night, a mixture of obstructive apneas and obstructive hypopneas with a respiratory disturbance index of 5.1. Anything over 5 is considered significant. The longest duration of anyone event was 34 seconds. O2 sat was between 76 and 95%, with 29% of the time spent with O2 sats less than 88%. Heart rate varied between 55 and 113, somewhat varying with the obstructive events. The patient had grade 1-2 snoring noted, and respiratory disturbance events were most evident in REM while supine. All five stages of sleep were represented. Basically the only thing abnormal was a reduced amount of REM.
OVERALL IMPRESSION: This patient has significant obstructive sleep apnea based on the respiratory disturbance index of 5.1. which anything over 5 is considered significant, plus the amount of time that the patient spent hypoxic, at less than 88%. 29% of the time was spent that way. So I suspect that the patient does have significant obstructive sleep apnea. We will need a second sitting to do the CPAP titration.
The overall impression is obstructive sleep