codedog
True Blue
There is no size ,so do I code this to the smallest size or do I look at path report ?Also,path report came out as a lipoma, but I only see the skin was closed with sutures , so is this integumentary?
Thanks
PREOPERATIVE DIAGNOSIS: Right arm mass.
POSTOPERATIVE DIAGNOSIS: Right arm mass.
PROCEDURE PERFORMED: Excisional biopsy of right arm mass.
ANESTHESIA: MAC.
ESTIMATED BLOOD LOSS: Minimal.
CLINICAL HISTORY: This is a patient with a right arm mass, consented for biopsy.
PROCEDURE IN DETAIL: The patient was brought into the operating room and placed on the operating room table in a supine position. The right arm was prepped and draped in a sterile fashion. A 10 cc of 1% lidocaine with epinephrine was injected for local anesthesia. A linear incision was made directly over the mass and subcutaneous tissue. A mass was excised with combination of blunt dissection and electrocautery with negative margins. It was consistent lipoma. The wound was inspected and found to be hemostatic and was irrigated with normal saline. The skin was closed with sutures. The patient tolerated the procedure well.
Thanks
PREOPERATIVE DIAGNOSIS: Right arm mass.
POSTOPERATIVE DIAGNOSIS: Right arm mass.
PROCEDURE PERFORMED: Excisional biopsy of right arm mass.
ANESTHESIA: MAC.
ESTIMATED BLOOD LOSS: Minimal.
CLINICAL HISTORY: This is a patient with a right arm mass, consented for biopsy.
PROCEDURE IN DETAIL: The patient was brought into the operating room and placed on the operating room table in a supine position. The right arm was prepped and draped in a sterile fashion. A 10 cc of 1% lidocaine with epinephrine was injected for local anesthesia. A linear incision was made directly over the mass and subcutaneous tissue. A mass was excised with combination of blunt dissection and electrocautery with negative margins. It was consistent lipoma. The wound was inspected and found to be hemostatic and was irrigated with normal saline. The skin was closed with sutures. The patient tolerated the procedure well.