AUDIT REPORT T13.2 OPERATIVE REPORT, MYRINGOTOMY

question 3

Essay

AUDIT REPORT T13.2 OPERATIVE REPORT, MYRINGOTOMY
WITH TYMPANOSTOMY TUBE PLACEMENT
PREOPERATIVE DIAGNOSIS: Chronic otitis media with effusion, bilateral Eustachian tube dysfunction
POSTOPERATIVE DIAGNOSIS: Chronic otitis media with effusion, bilateral Eustachian tube dysfunction
PROCEDURE PERFORMED: Bilateral myringotomies and tympanostomy tube placement
ANESTHESIA: General anesthetic by inhalational mask technique
PROCEDURE: Following informed consent from the parents, the child was taken to the operating room and placed supine on the operating table. The appropriate monitoring devices were placed on the patient. General anesthesia was induced. It was maintained by inhalational mask technique. The right ear was initially evaluated. Wax was removed. A radial incision was made at the 6 o'clock position on the right tympanic membrane. A large amount of thick mucoid effusion was suctioned. A tube was placed. Topical antibiotic drops were then applied. The patient then had the left ear evaluated. Wax was removed. A radial incision was made at the 6 o'clock position on the left tympanic membrane. A large amount of mucoid effusion was suctioned from behind the left tympanic membrane. A tube was then placed. Topical antibiotic drops were then applied. The patient was then allowed to recover from general anesthesia. She was transferred to the recovery room in good condition. She tolerated the procedure well.
T13.2:
SERVICE CODE(S): 69420_________________
ICD-10-CM DX CODE(S): H66.93___________
INCORRECT/MISSING CODE(S): ________________________________________

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