Case
-T10-1B OPERATIVE REPORT, URETEROSCOPIC STONE EXTRACTION
LOCATION: Outpatient, Hospital
PATIENT: Don Dwell
SURGEON: Ira Avila, MD
PREOPERATIVE DIAGNOSIS: Left ureteral calculus
POSTOPERATIVE DIAGNOSIS: Left ureteral calculus
PROCEDURE PERFORMED: Left ureteroscopic stone extraction under fluoroscopic control
CLINICAL NOTE: The patient is a 50-year-old gentleman with intermittent left renal colic and left distal ureteral stone that has not passed spontaneously.
PROCEDURE: The patient was given a general endotracheal anesthesia, prepped, and draped in the lithotomy position. A 21-French cystoscope was passed into the bladder under direct vision. The urethra was normal. The bladder was normal. The prostate was not obstructed. A guidewire was then advanced up to the left ureter beyond the stone under fluoroscopic control. The patient was ureteroscoped without prior ureteral dilation using a 7-French rigid scope. The stone was visualized, grasped within a 0-tip basket, and withdrawn intact. Repeat ureteroscopy showed no evidence of ureteral abrasion or edema. It was decided not to stent the patient. The bladder was drained. The scope was withdrawn. B and O suppository was placed rectally. The patient was transferred to the recovery room in good condition. We will schedule him for renal ultrasound, KUB (kidney, ureter, bladder), and follow-up in 3 months' time. The stone will be shown to the patient and then sent for analysis.
PATHOLOGY REPORT LATER INDICATED: Benign calculi
T10-1B:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________

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The Answer of Case
-T10-1B OPERATIVE REPORT, URETEROSCOPIC STONE EXTRACTION
LOCATION: Outpatient, Hospital
PATIENT: Don Dwell
SURGEON: Ira Avila, MD
PREOPERATIVE DIAGNOSIS: Left ureteral calculus
POSTOPERATIVE DIAGNOSIS: Left ureteral calculus
PROCEDURE PERFORMED: Left ureteroscopic stone extraction under fluoroscopic control
CLINICAL NOTE: The patient is a 50-year-old gentleman with intermittent left renal colic and left distal ureteral stone that has not passed spontaneously.
PROCEDURE: The patient was given a general endotracheal anesthesia, prepped, and draped in the lithotomy position. A 21-French cystoscope was passed into the bladder under direct vision. The urethra was normal. The bladder was normal. The prostate was not obstructed. A guidewire was then advanced up to the left ureter beyond the stone under fluoroscopic control. The patient was ureteroscoped without prior ureteral dilation using a 7-French rigid scope. The stone was visualized, grasped within a 0-tip basket, and withdrawn intact. Repeat ureteroscopy showed no evidence of ureteral abrasion or edema. It was decided not to stent the patient. The bladder was drained. The scope was withdrawn. B and O suppository was placed rectally. The patient was transferred to the recovery room in good condition. We will schedule him for renal ultrasound, KUB (kidney, ureter, bladder), and follow-up in 3 months' time. The stone will be shown to the patient and then sent for analysis.
PATHOLOGY REPORT LATER INDICATED: Benign calculi
T10-1B:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________

Case -T10-1B OPERATIVE REPORT, URETEROSCOPIC STONE EXTRACTION