cpccoder2008
True Blue
can someone help me with the op report
Preop Dx: a skin lesion of the left palm
Operations: Shave biopsy of the skin lesion of the left palm.
Procedure in detail: This is a 52 year old man who had about a 2 cm x 2 cm skin lesion of the palm of the left hand. It appeared to be some sort of keratic lesion. However, it had been growing and we wished to obtain a biopsy to make sure this lesion was benign. Plan is to obtain a biopsy and refer the patient to Dermat if indeed it is a benign lesion. Therefore, the wound was prepped and using 0.5% Marcain plain, this was injected in and around the lesion. Using a #15 blade, two small areas of the lesion were removed and sent to pathology. The wound was cleaned and a pressure dressing was applied and the patient will follow up with me in a week and we will setup his Dermatology refferal and know the pathology at that time.
Preop Dx: a skin lesion of the left palm
Operations: Shave biopsy of the skin lesion of the left palm.
Procedure in detail: This is a 52 year old man who had about a 2 cm x 2 cm skin lesion of the palm of the left hand. It appeared to be some sort of keratic lesion. However, it had been growing and we wished to obtain a biopsy to make sure this lesion was benign. Plan is to obtain a biopsy and refer the patient to Dermat if indeed it is a benign lesion. Therefore, the wound was prepped and using 0.5% Marcain plain, this was injected in and around the lesion. Using a #15 blade, two small areas of the lesion were removed and sent to pathology. The wound was cleaned and a pressure dressing was applied and the patient will follow up with me in a week and we will setup his Dermatology refferal and know the pathology at that time.