AAPC - Chapter 4 Practical Applications

CASE 1 Operative Report PREOPERATIVE DIAGNOSES: Splenic abscesses and multiple intra-abdominal abscesses, related to HIV, AIDS, and hepatitis C. POSTOPERATIVE DIAGNOSES: Splenic abscesses and multiple intra-abdominal abscesses, related to HIV, AIDS, and hepatitis C. (Postoperative diagnoses are reported.) OPERATIVE PROCEDURE: 1. Exploratory laparotomy with drainage of multiple intra-abdominal abscesses. 2. Splenectomy. 3. Vac Pak closure. FINDINGS: This is a 42-year-old man who was recently admitted to the medical service with a splenic defect and found to a splenic vein thrombosis. He was treated with antibiotics and anticoagulation. He returned and was admitted with a CT scan showing mass of left upper quadrant with abscesses surrounding both sides of the spleen(The location of the abscesses are on both sides of the spleen.), as well as, multiple other intra-abdominal abscesses below the left lobe of the li - B20, D73.3, K65.1, B19.20