QUESTION: This is an authentic coding case for an Outpatient Clinic case for Musculoskeletal DiseasesPlease review the documentation of the patient encounter and code the case. You may use ICD-10-CM including External Cause Codes, CPT, and HCPCS codes. Today it is my pleasure to see a 1O year old Pediatric Surgical Clinic for consultation of removal of foreign bodv in the posterior right thigh. She is accompanied to clinic today by her mother. Per the mother, fell through a glass table just before her fourth birthday. A large piece of glass was surgically removed at that time and the mother states that the surgeon felt that all of it was removed. Two years later, She was doing a handstand on a couch and when she tumbled down another piece of glass was visible protruding from an opening of her right thigh. She was again scheduled for surgery, however when she was walking up the stairs, the mother states that it migrated out on its own and fell out just prior to her procedure. The second surgical procedure was then cancelled. About a year ago, pulled her right hamstring when tumbling in gymnastics. She continues to complain of pain in the area and for the last month has been having physical therapy. Per the mother, the physical therapy has softened the scar tissue and helped to repair the hamstring however there remain to be two palpable masses that are not resolving and thus warranted further investigation. She received an ultrasound last month that demonstrated two retained foreign bodies in the posterior right thigh. and her mother would like for these to be removed so that they do not cause further damage She was a full term infant who is otherwise medically healthy. She has a past surgical history of foreign body removal at three years of age. She takes a daily multivitamin, has NKDA, and her immunizations are stated to be up to date. The mother denies any family history of bleeding disorders or reactions to anesthesia. The mother states that she does have a sensitivity to Morphine that causes her to vomit. A pertinent review of the skin, head, eyes, ears, nose, mouth, throat, respiratory, cardiovascular, genitourinary, allergic, immunologic, endocrine, gastrointestinal, neurologic, psychiatric, musculoskeletal and lymphatic systems, except as noted, are otherwise negative. In general, , She is calm, cooperative, and in no apparent distress. The head and neck are unremarkable. Bilateral sclera are clear, anicteric. PERRL. EOMI. MMM. Neck is soft and supple. Lungs are CTA bilaterally without any noted wheezing. There is a clear S 1-S2 without any noted murmur. The abdomen is soft, non-tender, and non-distended. There is no appreciable lymphadenopathy or organomegaly noted. The skin is without rash. There is a surgical incisional scar on her right medial thigh, close to the groin. There are two palpable foreign bodies present in the posterior right thigh. There is no pain to palpation or overlying erythema. There is no overlying ecchymoses or edema. FROM noted in all extremities with a straight spine and steady gait. The patient is neurologically age appropriate with bilateral strength and sensation intact DATA: Ultrasound – Two foreign bodies in the palpable area of concern which are consistent with glass given the history. In summary, is an otherwise healthy 10 year old female with retained foreign bodies in her right posterior thigh. These foreign bodies have been verified with ultrasound and it is appropriate to surgically remove them. We discussed the risks and benefits of removing them with . and her mother and both have requested that we proceed. The mother has provided written surgical consent today in clinic and has been scheduled for removal of these foreign bodies. This is anticipated to be an outpatient procedure and she should be able to go home the same day. In the interim we have provided the family with the contact information to the Pediatric Surgical Service and encouraged them to contact us with any further questions or concerns. Thank you for referring and her family to the Pediatric Surgical Service. We appreciate the opportunity to participate in this aspect of her care. Discharge Instructions: Removal of foreign body from right posterior thigh Diet: No restrictions Bathing: May shower tonight. DO NOT soak wound in water for 2 weeks. No swimming or sitting in a tub during that time Activity: No swimming (until incisions well healed)Call us if: Temperature over 101.5′ F Pain uncontrolled by medication Wound Care: Do your best to keep incision and surrounding area clean and dry Wash with regular mild soap and water daily Wash hands before and after caring for the wound Outer dressing consists of steri-strips. These wills start peeling on their own, but may be removed in 2 weeks. PREOPERATIVE DIAGNOSIS: Retained glass in the right posterior thigh. POSTOPERATIVE DIAGNOSIS: Retained glass in the right posterior thigh. OPERATION PERFORMED: Removal of glass piece from right posterior thigh. SURGEON: ASSISTANT SURGEON: ANESTHESIOLOGIST: INDICATIONS: This is a 10-year-old female who fell on a glass table as a toddler. At the time of the event, she had glass pieces removed from her right thigh; however, there has been a known piece of glass in her right posterior thigh that at the time was not believed to be safe to retrieve. However, as she has gotten older and more active, it is becoming more bothersome to her and will intermittently cause her pain. It is appropriate at this time to remove it. Procedure was described to her mother in detail. Questions answered and consent signed. DESCRIPTION OF PROCEDURE: Patient was brought to the Operating Room and placed on the table in the supine position. Following induction of inhaled and IV anesthetic, the right thigh was prepped and draped in a circumferential sterile fashion following the placement of a stockinette on the foot and lower extremity. There was a scar on her mid right posterior thigh, under which we were able to feel the foreign body. We made a 2cm incision over this area, and with blunt dissection were able to enter in a clean capsule and retrieve a rather large segment of glass. It was diamond-shaped and was approximately 1.5 x 5 cm in widest dimension. There was no other evidence of any foreign body remnant on palpation; however, there was an ultrasound report of there being two pieces of glass. Thus, we used intraoperative fluoroscopy for the area and did not notice any other foreign body. The area was then irrigated and closed using 4-0 Vicryl in the deep dermis followed by 5-0 Monocryl in an interrupted fashion to close the skin. Incision was then cleaned, dried, and dressed with Mastisol, Steri-Strips, followed by gauze and Tegaderm. Patient was then awoken from anesthesia and taken to the PACU in stable condition. I was present, scrubbed and participated in the entire case. Patient awake and alert, denies nausea and pain. Vital signs stable. IV discontinued. Out of bed to bathroom with minimal assist. Right thigh dressing CDI. Prescription filled at for pain medication. Procedure report, discharge and aftercare instructions provided to patient and mom, . Understanding verbalized. Transferred via wheel chair to front circle and discharge to home. Health Science Science Nursing HCMT 2025C Share QuestionEmailCopy link Comments (0)
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