POSTOPERATIVE DIAGNOSIS: Tumor of left vocal cord
OPERATION PERFORMED: Laryngoscopy.
The patient is a 25-year-old student of opera who presented with a lesion of her left
vocal cord seen on office laryngoscopy. Today she is seen in the ambulatory suite for
further examination of this lesion, using the operating microscope. After the
administration of local anesthesia, a direct endoscope is introduced. The operating microscope is brought into the field, and the pharynx and larynx are visualized. The
pharynx appears normal. There was a mass noted of the left vocal cord. The mass was
approximately 2.0cm in size and was removed in total and sent to pathology for
analysis. All secretions were suctioned, and the area was irrigated with saline. The
patient had minimal blood loss. It should be noted that the pathology report stated
benign tumor of the vocal cord
CPT CODE: __________________________
ICD-9-CM CODE: _____________________
3.) PREOPERATIVE DIAGNOSIS:Hemoptysis.
POSTOPERATIVE DIAGNOSIS:Mucosal lesion of bronchus.
The bronchoscopy was passed through the nose. The vocal cords were identified and appeared normal. No lesions were seen in this area. The larynx and trachea were then identified and also appeared normal with no lesions or bleeding. The main carina was sharp. All bronchial segments were visualized. There was an endobronchial mucosal lesion. This was located on the right lower lobe of the bronchus. The lesion was occluding the right lower lobe of the bronchus. No other lesions were seen. With use of fluoroscopic guidance, transbronchial biopsies were taken of the area of the lesion. Brush washings were also done for cytology analysis. The patient tolerated both procedures well and was sent to the recovery area in stable condition.
CPT CODE(S): ________________________________
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