PREOPERATIVE DIAGNOSIS Ascites and pleural effusion.
POSTOPERATIVE DIAGNOSIS
Ascites and pleural effusion
PRIMARY PROCEDURES
PARACENTESIS. THORACENTESIS.
age 2
PROCEDURE
A paracentesis of the abdomen was performed using a 24-gauge needle and 200 ml of straw-colored fluid was
withdrawn. Pressure was applied for 5 minutes to the puncture site. No complications were encountered. A 22-
gauge needle was then used to perform a right thoracentesis in the left lateral decubitus, and 75 ml of
serosanguineous fluid was withdrawn. Pressure was applied for 5 minutes to the puncture site with no significant
blood loss. Good bilateral breath sounds were auscultated following the procedure. Both fluid samples were sent
for cell count, acid fast stain, and glucose and protein levels. A culture and sensitivity was also ordered on both
samples. Nonmalignant ascites and exudative effusion confirmed by laboratory studies
ICD-10-CM
ICD-10-CM:
CPT :
CPT :