Question

Code this report as if you work for the hospital.

ROCEDURE: Excision of large, 4.5 cm, congenital nevus of the left arm and shoulder junction and z-plasty local tissue arrangement closure of large defect with extensive undermining.

OPERATION IN DETAIL: After sterile preparation and draping in the normal sterile fashion, and local infiltration with anesthetic, the lesion was excised and sent for pathological evaluation. The defect measured 4.8 x 2 cm. Z-plasty flaps were formed, preserving the neurovascular structures in the deep tissue as much as possible. The defect created by the flaps measured 9.6 x 2.3. The undermining was done at the fascial/subcutaneous level leaving some definitive soft tissue under the dermis for blood supply and suture closure. After mobilizing the flaps on both sides, 3-0 PDS suture was used to take the tension off of the flap closure, placing it into a superficial fascial system in the subcutaneous tissue. After this was accomplished, the deep dermis was closed using 4-0 PDS suture. The intermediate dermis was closed using 5-0 PDS suture in and a running intracuticular 6-0 PDS suture was used on the skin.

The patient tolerated the procedure well. No complications occurred throughout. The patient is very athletic. All of the risks involving postoperative concerns of this were discussed with the patient. The patient was given an extra supply of Steri-Strip and Mastisol to bring home. Dermabond and Steri-Strip were placed on the incision after the procedure. The patient tolerated the procedure well and was given prescriptions for antibiotics and pain medications. She will follow up in 2-4 weeks or p.r.n. if she has any problems sooner.

Answer 1

POST OPERATIVE DIAGNOSIS:Congenital melanocytic nevi over left arm and shoulder.

PROCEDURE: Cogwheel pattern serial excision.

ANESTHESIA:Local anesthesia

BLOOD LOSS: Not significant

SPECIMENT REMOVED:4.8 x 2 cm congenital nevus excised ,lesion sent for pathological evaluation.

COMPLICATIONS:Nil

POST OPERATIVE CARE AND ADVICE:

• Demonstration on placement of Steri-strip and Mastisol.
• To visit the doctor on signs of infection.
• Antibiotics and pain medications.
• Follow up in 2-3 weeks or sos.