Click below to sign up for the beta!
Chart Coder
Streamline your medical coding with automated code suggestions
Input anonymized health event
Results
Code suggestions from current ICD-10 codebook
Input more detailed chart data
PREOPERATIVE DIAGNOSIS
Right pleural effusion; suspected malignant mesothelioma
POSTOPERATIVE DIAGNOSIS
Right pleural effusion; suspected malignant mesothelioma
PROCEDURE
Right VATS pleurodesis and pleural biopsy
ANESTHESIA
General anesthesia via double-lumen endotracheal tube
FINDINGS
Right pleural effusion with scattered firm nodules throughout the right pleura and diaphragmatic surface
SPECIMENS
Pleural biopsies for pathology and microbiology
ESTIMATED BLOOD LOSS
Minimal
FLUIDS
1.2 L crystalloid; 1.9 L pleural fluid drained
INDICATIONS
A 66-year-old male presented with recurrent right pleural effusion, shortness of breath, and prior biopsy results suggestive of mesothelioma. Risks, benefits, and alternatives of right VATS pleurodesis and pleural biopsy were discussed; the patient and family opted to proceed.
PROCEDURE IN DETAIL
After informed consent, the patient was positioned and intubated with a double-lumen tube. The right thorax was prepped and draped. A 10 mm port was placed, and the pleural fluid was drained. Multiple firm nodules were palpated. An additional port was placed anteriorly for further drainage and pleural biopsies. Notably, nodules on the diaphragmatic surface appeared to possibly extend beyond the pleura. Following drainage, two cans of talc were sprayed for pleurodesis. The lung was reinflated, and a 32 French chest tube was placed. Incisions were closed, and the patient was extubated and transferred to recovery in stable condition.
Dr. X was present for the entire procedure.
Instrument and sponge counts were correct x2.