Case
-T12-1C DISCHARGE SUMMARY
LOCATION: Inpatient, Hospital
PATIENT: Rebecca Sole
ATTENDING PHYSICIAN: Timothy Pleasant, MD
SURGEON: Timothy Pleasant, MD
REASON FOR ADMISSION: Pain going down her left leg
She had an MRI (magnetic resonance imaging) done that showed a large disc at L4-5 (fourth lumbar vertebra-fifth) on the left. She had not responded to conservative measures. She is a truck driver.
EXAM: Chest: Clear. Cardiovascular exam: No murmurs. Abdomen: Soft.
I saw her in the office. She continued to have pain, which was refractory to conservative measures.
HOSPITAL COURSE: The patient underwent a laminotomy, foraminotomy, and removal of disc at L4-5. Her postoperative course was uneventful. The wound is clean. She is discharged to convalesce at home.
FINAL DIAGNOSIS: Herniated disc L4-5 on the left
PROCEDURE PERFORMED: Laminotomy, foraminotomy, and removal of disc
T12-1C:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________

Question

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The Answer of Case
-T12-1C DISCHARGE SUMMARY
LOCATION: Inpatient, Hospital
PATIENT: Rebecca Sole
ATTENDING PHYSICIAN: Timothy Pleasant, MD
SURGEON: Timothy Pleasant, MD
REASON FOR ADMISSION: Pain going down her left leg
She had an MRI (magnetic resonance imaging) done that showed a large disc at L4-5 (fourth lumbar vertebra-fifth) on the left. She had not responded to conservative measures. She is a truck driver.
EXAM: Chest: Clear. Cardiovascular exam: No murmurs. Abdomen: Soft.
I saw her in the office. She continued to have pain, which was refractory to conservative measures.
HOSPITAL COURSE: The patient underwent a laminotomy, foraminotomy, and removal of disc at L4-5. Her postoperative course was uneventful. The wound is clean. She is discharged to convalesce at home.
FINAL DIAGNOSIS: Herniated disc L4-5 on the left
PROCEDURE PERFORMED: Laminotomy, foraminotomy, and removal of disc
T12-1C:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________

Case -T12-1C DISCHARGE SUMMARY