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CPC sample question # 11


Preoperative Diagnosis: Acute respiratory failure and protein-caloric malnutrition.

Postoperative Diagnosis: Acute respiratory failure and protein-caloric malnutrition.

Procedures performed : Tracheostomy and percutaneous gastrostomy tube placment.

Findings: Esophagus and pylorus were normal. Estimated Blood Loss: Minimal.

Indications: Respiratory failure and malnutrition.

Description of Procedures: This 78-year-old patient underwent induction with general anesthesia. After having placed a shoulder  roll, the neck was prepared and drapped in the usual sterile fashion.

An open cutdown to the trachea was performed using a #10 blade sclpel. Dissection was undertaken utilizing the Bovie cautery. The strap muscles were divided in the middle and the thyroid was pulled superiorly. A tracheal hook was placed in the trachea and the endotracheal tube was then utilized and the needle was introduced into the trachea. The wire was fed and the appropriate steps utilizing the dilators were undertaken. A tracheostomy was placed.

Placement was confirmed and the trachea was secred into place utilizing interrupted nylon sutures. The incision was closed with an additional interrupted nylon suture.

Attention was then turned towards the placement of a feeding tube. An esophagogastroduo-denoscope was placed via the month and the esophagus was viewed. It was felt to be normal; therefore, the stomach was entered. There was no evidence of abnormality and the pylorus was well visualized. The abdominal wall was also prepped and draped at this time. The patient was morbidly obese and I was not able to gain adequate transillumination after entering the stomach and duodenum. By pushing on the abdominal wall, after determining location, a cutdown was made through the skin overlying the stomach utilizing a scalpel and Bovie cautery.

A retractor was placed. I was then able to transilluminate through the abdominal wall. A standard percutaneous endoscopic gastrostomy tube placement was performed. The needle was introduced and visualized as it passed. The wire was fed in and the grasper was utilized to grasp the wire. It was pulled out of the patient’s month along with the scope. The tube was secured to the wire and the wire was pulled back out through the abdominal wall, placing the percutaneous endoscopic gastrostomy tube. At this time, the scope was reintroduced and the percutaneous endoscopic gastrostomy tube placement was confirmed.


The abdominal wall was closed utilizing 3-0 Vicryl in an interrupted fashion followed by interruped 3-0 Ethilon sutures.


All sponge, needle, and instrument counts were correct. The patient left the operating room in good condition and there were no complications. Blood loss was minimal.

a.    43246, 31603-59, 518.82, 263.8
b.    43246, 31600-59, 518.81, 263.9
c.    43752, 31600-59, 480.1, 261
d.    43256, 31612-59, 786.09, 263.9

Answers

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