Location: Inpatient Hospital
OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS: Right staghorn calculus.
POSTOPERATIVE DIAGNOSIS: Same.
OPERATIVE PROCEDURE: Right ESWL (electric shock wave lithotripsy).
CLINICAL NOTE: This gentleman had a failed percutaneous nephrolithotripsy. He now is stented. The procedure was unsuccessful because of inability to access the kidney because of the stone. I decided to proceed with lithotripsy to see if we can create some more room, and maybe we will get lucky, but I told the patient he will likely require either multiple ESWLs or secondary attempt at PCN.
PROCEDURE NOTE: The patient was given a general laryngeal mask anesthetic, prepped and draped in the supine position on lithotripsy table, stone targeted, shock had engaged. Unfortunately, we had to do the procedure without the simulator. Therefore, it took a longer time, but the patient tolerated it well. A total of 3,000 shocks at a maximum kv of 24 were administered to the stone. Some fragmentation was noted. We will see the patient early next year to see how he is doing, to schedule further treatment as required.
CPT Code: ____________________

Question

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The Answer of Location: Inpatient Hospital
OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS: Right staghorn calculus.
POSTOPERATIVE DIAGNOSIS: Same.
OPERATIVE PROCEDURE: Right ESWL (electric shock wave lithotripsy).
CLINICAL NOTE: This gentleman had a failed percutaneous nephrolithotripsy. He now is stented. The procedure was unsuccessful because of inability to access the kidney because of the stone. I decided to proceed with lithotripsy to see if we can create some more room, and maybe we will get lucky, but I told the patient he will likely require either multiple ESWLs or secondary attempt at PCN.
PROCEDURE NOTE: The patient was given a general laryngeal mask anesthetic, prepped and draped in the supine position on lithotripsy table, stone targeted, shock had engaged. Unfortunately, we had to do the procedure without the simulator. Therefore, it took a longer time, but the patient tolerated it well. A total of 3,000 shocks at a maximum kv of 24 were administered to the stone. Some fragmentation was noted. We will see the patient early next year to see how he is doing, to schedule further treatment as required.
CPT Code: ____________________

Location: Inpatient Hospital OPERATIVE REPORT