1. case 410198 it has 4 codes. 2 Diagnosis Codes and 2 Procedure…

1. case 410198 it has 4 codes. 2 Diagnosis Codes and 2 Procedure… 1. case  410198 it has 4 codes. 2 Diagnosis Codes and 2 Procedure codes.List the Primary Diagnosis below.SUBJECTIVE:H&P (View-Only) Division of Plastic & Reconstructive Surgeryis a 49 y.o. female who is being seen for a lesion/mass of the left cheek. She had a cyst at the site many years ago , with either excision or drainage with resulting scar. Recently , she has noticed the scar has enlarged , become itchy and at times drains foul smelling material. She is otherwise healthy.ASSESSMENT:Benign skin or soft tissue lesion, most likely inclusion cyst or similar.PLAN:Discussed option of excision, with details provided about location, orientation and size of resulting scar.She states she has some anxiety with procedures and would like to have sedation or anesth for the case .PREOPERATIVE DIAGNOSIS: Soft tissue and skin lesion on the left cheek measuring 1 em in diameter.POSTOPERATIVE DIAGNOSIS: Soft tissue and skin lesion on the left cheek measuring 1 em in diameter.OPERATION PERFORMED: Excision of lesion, 1 em, from the left lower cheek with layered closure. SURGEONASSISTANT SURGEON: None. ANESTHESIOLOGIST:ASSISTANT ANESTHESIOLOGIST: ANESTHESIA:SPECIMEN: Specimen to pathology.HISTORY: This is a woman we saw in clinic with a history and exam consistent with benign lesion of cystic nature of the left lower cheek that has been present for many years, slowly enlarging and intermittently draining. She wished to have it removed. We discussed excision, placement, and size of a resulting scar. We discussed additional risks and benefits, and after answering all s, a signed written consent was obtained.PROCEDURE IN DETAIL: The patient was met in Preoperative Holding. The operative site was marked. There were no new concerns. The operative plan was reviewed. The patient was brought to the Operating Room and the full team time-out was performed. The patient had lower extremity SCDs placed and turned on, and underwent general anesthesia in the supine position with abundant padding of her extremities and joints. No preoperative antibiotics were given due to the simple skin nature of this and the location of the face. The area was prepped and draped In the usual sterile fashion. A second staged time-out was performed. Preoperative markings were confirmed and oriented in acurvilinear vertical manner to coincide with the natural crease of the inferior extension of the nasolabial crease down towards the chin, also known as the marionette lines. An elliptical-type excision was incorporated with the closure to fall within this crease. The area was infiltrated with 5 ml of 0.25% Marcaine with epinephrine. After time for a vasoconstrictive effect, the incision was carried downthrough the skin into the subcutaneous layer. Sharp dissection was performed to envelope any scar- appearing tissue and firm nodular tissue . The lesion was rem oved and sent off the fie ld fo r routine pathology examination. The area was treated with electrocautery for hemostasis and closed in 2 layers with 3-0 Monocryl and 4-0 Monocryl, Steri-Strips as a dressing. This completed the operation. A layered closure was approximately 1.4 em in length. There were no known complications. Estimated blood loss was 5 m l or less. I was present and performed the operation. The patient was awakened and taken to the Recovery Room in stable condition.medication: 0.9 % NaCI infusionRate: 50 mUhr Freq: CONTINUOUS Route: IVacetaminophen (TYLENOL) tablet 325-650 mg Dose: 325-650 mg Freq: ONCE PRN Route: POPRN Reason: mild painHYDROmorphone HCI PF (DILAUDID) injection 0.5 mgDose: 0.5 mg Freq: EVERY 5 MIN PRN Route: IVondansetron (ZOFRAN) injection 4 mgoxyCODONE-acetaminophen (PERCOCET) 5- 325 MG per tablet 5-10 mg  Health Science Science Nursing HIMT 2224 Share EmailCopy link Comments (0)

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