AAPC - Chapter 9 Practical Applications

CASE 1 Preoperative Diagnosis: Recurrent pleural effusion, stage IV right lung cancer. Postoperative Diagnosis: Recurrent pleural effusion, stage IV right lung cancer.(Report this diagnosis if no further findings are found in the notes.) Procedure Performed: Video-assisted thoracoscopy,(Indication the procedure is being performed by Video Assisted Thoracic Surgery (VATS).) lysis of adhesions, talc pleurodesis Procedure: Patient was brought to the operating room and placed in supine position. IV sedation and general anesthesia were administered, per the anesthesia department. A double-lumen endotracheal tube was placed, per anesthesia. The position was confirmed by bronchoscopy. The patient was placed in the decubitus position with the right side up. The chest was prepped in the standard fashion with ChloraPrep, sterile towels, sheets, and drapes. A small incision is made between two ribs and a standard port place - 32650-RT J90 C34.91