Please provide the following ICD-10 codes for the following along…
Please provide the following ICD-10 codes for the following along with references.
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PREOPERATIVE DIAGNOSIS: Gunshot wound to left thigh.
POSTOPERATIVE DIAGNOSIS: Gunshot wound to left thigh with transection of superficial femoral artery and veins.
PROCEDURE PERFORMED: Exploratory laparotomy with control of left external iliac artery. Debridement of left thigh wound. Repair of left superficial femoral artery using a right greater saphenous vein interposition vein graft. Repair of left superficial femoral vein. Ligation of branch of left profunda femoris artery. Fasciotomy left lower leg.
SURGEON: Marsha Petros, MD
ANESTHESIA: General anesthesia.
INDICATIONS FOR SURGERY: This patient is a 27-year-old Caucasian male who was shot in the left thigh. The exact cause or how the incident occurred is unknown. The patient was initially seen in Anytown and was transferred to Central Hospital for treatment.
DESCRIPTION OF PROCEDURE: The patient was bleeding from the left thigh. The prep was just Betadine solution splashed on the skin. An abdominal incision was then made and the iliac artery on the left side was isolated with a vessel loop and clamp. This controlled the bleeding. The left thigh incision was then opened from the gunshot wound to the groin area. There was a large clot in this area and this whole area was opened. Upon examination there was oozing and bleeding from the torn muscle. The proximal and distal end of the superficial femoral artery was found. There was a large segment missing. The superficial femoral vein was also found and this was repaired. The holes that were in the vein were found and repaired. The nerves of the left thigh were not seen.
A repair of the left superficial femoral artery was then done. The right groin area was dissected and the right greater saphenous vein on the upper thigh was excised. The branches of the vein were ligated with 3-0 silk sutures and divided. At the junction of the right femoral vein a vascular clamp was then placed across the saphenous vein. The saphenous vein was then transected. The saphenous vein was then oversewn with a running 4-0 Prolene suture. Clamp was then removed. The dissection was then carried out distally for at least 8 inches. The saphenous vein was then harvested. The distal end was tied with a 2-0 silk suture, and the vein was then removed. The vein was irrigated and was brought into the left wound area. The proximal end of the left superficial femoral artery was then trimmed back to normal tissue.
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