amandaeholt
New
I am having trouble with this. Would this be L72.0 and 11400? I feel like there are conflicting dx on the procedure report and the path. I'm new to this! Thank you.
PREOPERATIVE DIAGNOSIS: Umbilical Cyst
POSTOPERATIVE DIAGNOSIS: Same.
PROCEDURE: Umbilical cyst excision
INDICATIONS FOR PROCEDURE: 6 y/o F with a lifelong history of an umbilical cyst. She presented to clinic and requested removal.
OPERATIVE FINDINGS: umbilical cyst excised
DESCRIPTION OF PROCEDURE:
The patient was properly identified and brought to the operating room. General anesthesia was induced and maintained. The patient was properly positioned and the surgical site was prepped and draped in the usual manner. After a final time-out and site check, the surgical incision was made around the base of the umbilical cyst circumferentially. The base was explored for any underlying connection at the stump. During exploration the cyst was entered and a small amount of thick dark content was expressed.There was no obvious connection and cautery was used to excise the lesion completey. The fascia was explored for any defects and a small 1-2 mm defect was found and repaired with a simple interrupted 4-0 vicryl. Deep tissue was closed with a 4-0 vicryl in a figure of eight fashion. A 4-0 monocryl was used to close the defect at the skin in a pursestring fashion recreating the umbilicus. Dermabond and steri-strips were applied.
Pathology results:
A. Skin, umbilical cyst, excision:
- Epidermal inclusion cyst.
CLINICAL HISTORY:
Umbilical cyst
PRE-OPERATIVE DIAGNOSIS
Umbilical cyst
POST-OPERATIVE DIAGNOSIS
Same
PREOPERATIVE DIAGNOSIS: Umbilical Cyst
POSTOPERATIVE DIAGNOSIS: Same.
PROCEDURE: Umbilical cyst excision
INDICATIONS FOR PROCEDURE: 6 y/o F with a lifelong history of an umbilical cyst. She presented to clinic and requested removal.
OPERATIVE FINDINGS: umbilical cyst excised
DESCRIPTION OF PROCEDURE:
The patient was properly identified and brought to the operating room. General anesthesia was induced and maintained. The patient was properly positioned and the surgical site was prepped and draped in the usual manner. After a final time-out and site check, the surgical incision was made around the base of the umbilical cyst circumferentially. The base was explored for any underlying connection at the stump. During exploration the cyst was entered and a small amount of thick dark content was expressed.There was no obvious connection and cautery was used to excise the lesion completey. The fascia was explored for any defects and a small 1-2 mm defect was found and repaired with a simple interrupted 4-0 vicryl. Deep tissue was closed with a 4-0 vicryl in a figure of eight fashion. A 4-0 monocryl was used to close the defect at the skin in a pursestring fashion recreating the umbilicus. Dermabond and steri-strips were applied.
Pathology results:
A. Skin, umbilical cyst, excision:
- Epidermal inclusion cyst.
CLINICAL HISTORY:
Umbilical cyst
PRE-OPERATIVE DIAGNOSIS
Umbilical cyst
POST-OPERATIVE DIAGNOSIS
Same