# Skin Removal after Vaginal Tear?!



## anne32 (May 1, 2014)

I have not idea what CPT code this should go under. HELP!


  1. Vaginal skin remove. 2. Not a smoker.  

 HPI: 
   Midtown General HPI:  
       Pt has some protruding flesh from vagina thta has been bothersome and wants it excised. It resulted after delivery of last child and tear or episiotomy that allowed the "skin tag" - like protrusion. No pain or any other related sx. Desires the excision of this nuisance soft tissue. 

 ROS:  
   CONSTITUTIONAL:  
       Negative For Fever, Chills, N/V/D.     
   CARDIOLOGY:  
       Negative for dizziness, chest pain, shortness of breath.     
   RESPIRATORY:  
       Negative for shortness of breath, wheezing, persistent cough.     


 Gyn History:  LMP  03/27/14.  Abnormal Menstruations  yes only 1 day.  Dysmenorrhea  no.  Last Pap Smear Date  2 yr.  Last Mammogram Date  unsure.  Abnormal Pap Smear  unsure.   

 OB History:  Total pregnancies  5.  Total living children  5.  Abortion(s)  no.   

 Surgical History: ball on her L breast removed 1999.  

 Hospitalization/Major Diagnostic Procedure: ball on her L breast removed 1999.  

 Family History:  Father: alive Mother: deceased 2 brother(s) , 4 sister(s) - healthy. 4 son(s) , 1 daughter(s) - healthy.  

 Social History:  Smoking  Status:  Never. Chewing Tobacco: no. Caffeine use: no. Recreational Drug Use/ Substance Abuse: no. Alcohol: No. Occupation: Not working. Marital Status: Single. Lives With: with children. Education Level: High School. Language: French. Exercise: no. Country of Birth: Haiti. Self-Referral: No. Tobacco Exposure: No. Animal Exposures: no pets in the home.  

 Medications: None 

 Allergies: ibuprofen: face swollen,itchy, Alka-Seltzer Anti-Gas: face swollen,re eyes.  


Objective:

 Vitals: Pain scale 0, Wt 177 lb 6 oz, Ht 5 ft 4 in, BMI 30.44, BP 110/61, Temp 98.3, RR 18, HR 70. 

 Examination: 
   General Examination: 
       General Appearance NAD, pleasant, alert and oriented, well groomed, well nourished and hydrated, answers questions appropriately.  FEMALE GENITOURINARY:  Small area of soft tissue, appears as polypated vaginal mucosas protruding slightly from vaginal opening.      



Assessment:

 Assessment: 
1. Proud flesh - 701.5 (Primary)   

Plan:

 1. Proud flesh  
After consent obtained and tome out observed pt was placed in lithotomy posisiotn after which, under sterile conditions, 1.5 cc 1% Lido with Epi wa sinfiltrated into the base of the polyp and 3 minutes was allowed with good anesthesia achieved. the base of the lesion was then tied off with 4-0 Ethilon suture material and excised usinng a sharp scissors. Minimal bleeding and no complications were experienced.


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