Nervous System, Eyes, Ears, EndocrinePreoperative diagnosis:…
Nervous System, Eyes, Ears, EndocrinePreoperative diagnosis: Right subdural hematomaPostoperative diagnosis: Right subdural hematomaProcedure performed: Right temporoparietal craniotomy for evacuation of subdural hematomaAnesthesia: General endotrachealComplications: NoneConditions: StableIndications for procedure: Mr. Green is a 45-year-old male with a known history of alcoholism. He reported falling today, with loss of consciousness for about 20 minutes. Upon arrival at the ED, he was minimally responsive, with some spontaneous movement on the right side. He was intubated and taken to CT, which demonstrated a large right temporal subdural hematoma with 2.5-cm midline shift and effacement of the right lateral ventricle.Description of procedure: The patient was brought to the OR already intubated. General anesthesia was induced. He was given Ancef for preoperative prophylactic IV antibiotics. Lacri-Lube was placed in both eyes, which were then taped shut. A Foley was placed. The patient was positioned supine on the operating room table with the right side elevated with a gel roll. The head was secured in the three-point Mayfield head-holder with the right side up. All pressure points were inspected and padded adequately. The patient’s scalp was clipped, prepped, and draped in standard sterile surgical fashion. Local anesthetic was infiltrated along the line of the planned skin incision. A right temporoparietal inverted-question-mark incision was performed with a #10 blade down to the level of the periosteum. The scalp flap, along with the muscle and periosteum, was elevated and reflected anteriorly and held in place with fishhooks. Raney clips were applied to the skin edges. Using the high-speed Midas Rex drill with the perforator bit, burr holes were placed in the temporoparietal region, and they were connected with the B1 and footplate. The bone flap was elevated from the dura and set aside. The underlying brain appeared to be tense. The dura was opened with a 15-blade, and a large amount of subdural hematoma was immediately released. The subdural space was copiously irrigated, and hemostasis was achieved.Select the appropriate ICD-10-CM and CPT code(s):