Case -T5-2A OPERATIVE REPORT, NEVUS EXCISION

Essay

Case
-T5-2A OPERATIVE REPORT, NEVUS EXCISION
LOCATION: Outpatient, Hospital
PATIENT: Morgan Goldstein
SURGEON: Gary Sanchez, MD
ATTENDING PHYSICIAN: Gary Sanchez, MD
INDICATION: This patient had a large raised congenital nevus in the posterior aspect of the right arm, which although it does not meet the usual criteria for a giant congenital nevus, it has become somewhat raised and increasingly darkly pigmented.
PREOPERATIVE DIAGNOSIS: Compound (congenital) nevus, posterior aspect, right arm
POSTOPERATIVE DIAGNOSIS: Compound (congenital) nevus, posterior aspect, right arm
SURGICAL FINDINGS: A 1.5-cm (centimeter) raised, darkly pigmented, hairy lesion of the posterior aspect of the right arm overlying the insertion of the deltoid muscle
SURGICAL PROCEDURE: Excision of compound (congenital) nevus, posterior aspect, right arm
ANESTHESIA: General inhalation anesthesia plus 5 cc (cubic centimeter) of 1% Xylocaine with 1:100,000 epinephrine
DESCRIPTION OF PROCEDURE: Under satisfactory general inhalation anesthesia, the patient's right arm was prepped with Betadine scrub and solution under sterile conditions and draped in the routine sterile fashion. An ellipse was marked out around the lesion in a diagonal fashion, and I injected 5 cc of 1% Xylocaine with 1:100,000 epinephrine. The lesion was excised elliptically at the superficial layer of the subcutaneous tissue, and bleeding was carefully electrocoagulated with the pickups and the cautery set at 20. The wound was closed with interrupted subcuticular 4-0 Monocryl sutures, and Steri-Strips were then applied. The dressing consisted of Xeroform, three Kerlix fluffs, Kerlix roll, Kling, and a 3-inch Ace bandage. The patient tolerated the procedure well and left the operating room in good condition. Estimated blood loss was zero.
PATHOLOGY REPORT LATER INDICATED: Benign tissue
T5-2A:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________