Case Operative Report Explained for Students (Easy Guide)

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CASE 8-4 Operative Report, Preauricular Area Excision LOCATION: Outpatient, Hospital PATIENT: Doris Fisher SURGEON: Mohomad Almaz, MD PREOPERATIVE DIAGNOSIS: Malignant melanoma, skin of left preauricular area POSTOPERATIVE DIAGNOSIS: Malignant melanomas with clear margins on the skin of the left preauricular area PROCEDURE PERFORMED:Wide excision (this indicates radical excision) of malignant melanoma, skin of left preauricular area ANESTHESIA: General endotracheal with supplementary 1% Xylocaine with 1:800,000 epinephrine ESTIMATED BLOOD LOSS: Approximately 25 cc (cubic centimeter) PROCEDURE:The patient’s left face and ear were prepped with Betadine scrub and solution and draped in a routine sterile fashion. The 0.8-cm lesion was excised to include the crus of the left ear in the dissection, because this was the only method to provide at least 2 cm (centimeter) of width around the excision site. We were able to get about 2.5 cm on the anterior excision site and at least 3 cm proximally and distally. We submitted the specimen, tagging the superior aspect with a silk suture, and cauterized the bleeding. A small section of the fascia and muscle was repaired, and then, using separate instrument and gloves, we undermined the skin after the manner of a subcutaneous facelift and brought the skin up, suturing it to the more posterior edge with interrupted 3-0 Prolene. We dressed the wound with Xeroform, Kerlix fluffs, and a Kerlix roll plus Kling. The patient tolerated the procedure well and left the operating table in good condition. Pathology Report Later Indicated:Malignant melanoma. SERVICE CODE(S): ICD-10-CM DX CODE(S):

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