Can someone help me code this case please?
3. Preoperative Diagnosis: Right hilar mass per CT scan 1 month ago
Postoperative Diagnosis: Right hilar mass with widening of right secondary carina
Extrinsic compression of the right upper lobe
Procedure: Fiberoptic bronchoscopy with biopsy
Indications:
Patient is a 59-year old male with history of non-small cell lung cancer involving the left upper lobe
with metastasis to the left adrenal gland. He completed 28 treatments of radiationtherapy to the
chest and 10 treatments to the left adrenal gland. He was unable to tolerate chemotherapy due to
side effects and was stopped prior to completion. CT scan performed 1 month ago revealed right hilar
mass.
Findings:
The false and true vocal cords are normal. The carina and tracheal are normal.
Procedure:
Airways demonstrated widening of the right secondary carina and 75% extrinsic compression of the
right upper lobe with patency of the anterior and posterior segments visible. The apical segment was
not visualized and likely compressed.
Washings were taken from the segmental bronchi throughout both lungs. Bronchial alveolar lavage
was done in the right upper lobe. A central needle aspirate was done in the right mainstem and right
secondary carina. Transbronchial lung biopsies were taken from the right upper lobe.
PATHOLOGIC DIAGNOSIS:
Per microscopic examination and cyothpathologic exam, recurrence of poorly differentiated
adenocarcinoma in the mainstem bronchus and carina