Code this case: Anesthesia: General Pre-Surgical Diagnosis:

Code this case: Anesthesia: General Pre-Surgical Diagnosis: Aftercare following surgery Post-Surgical Diagnosis: Aftercare following surgery Procedure Performed: Cranioplasty with autograft, 3 cm; Retrieval of bone graft and repair of skull from previous craniectomy. History: A 40- year-old male is being seen today for retrieval of bone graft and repair of skull from previous craniectomy. Patient has history of hypertension, controlled with medication. Patient sustained a fall a week ago and was still experiencing slight headache and drowsiness. After being referred to receive an MRI, the results indicated subdermal brain hematoma. Patient received emergency surgery to evacuate tumor and is here today to repair skull from previous surgery. The patient was prepped for surgery. The patient’s hair was shaved in preparation for the procedure. The previous surgical site was accessed, and the bone graft was retrieved from the abdominal region and applied to the scalp. There was minimal reshaping done and patient tolerated procedure well. Follow up in the office in 1 week for post-operative follow up. SCIENCE

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