Scenario 5

PREOPERATIVE DIAGNOSIS
Subdural hematoma.

POSTOPERATIVE DIAGNOSIS
Same.

PRIMARY PROCEDURE
BURR HOLE FOR EVACUATION AND DRAINAGE OF SUBDURAL HEMATOMA.

BRIEF HISTORY
The patient is a 16-year-old student. During cheerleading practice at her high school, she was standing on the top of a “human pyramid,” lost her balance and fell on her head hitting the right side. She immediately felt drowsy and confused. By the time the paramedics arrived, she complained of a unilateral headache on the right side. Pupillary dilation was ipsilateral to the injured side. At the hospital, the location of the hematoma was located by angiography followed by x-ray and a CT scan.

PROCEDURE
The consent form was signed by the parents, and the patient was taken to the operating room. She was anesthetized, and the right frontotemporal region was prepped and draped. A burr hole, using a rounded tip, was made into the skull. Immediate evacuation and decompression resulted. The patient’s vitals were stable, and she was discharged to the neurosurgeon for evaluation of a craniotomy.

Note: External Cause code(s) apply.
ICD-10-CM:
ICD-10-CM:
ICD-10-CM:
ICD-10-CM:
CPT: