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Preоperаtive аnd pоstоperаtive diagnosis: Lesion of vulva, pathology pending Procedure: Deep destruction of 5 lesions of the vulva via cryosurgery Code(s):_____________________
Extrа Credit Operаtive Nоte Preоperаtive Diagnоsis: History of Colon Polyps Postoperative Diagnosis: Polyp of Colon Procedure: Colonoscopy and polypectomy Indications: The patient is a 46-year-old who had a polyp removed a little over a year ago and presents for a follow up at this time. Findings: The patient was taken to the Procedure Room and placed in the supine position. The patient was given initially 50mg of Demerol and 3mg of Versed. Next, a rectal exam was performed and the scope was introduced. The prep was poor. The scope could be passed up to an area of about 35 cm and a polyp was found. It was removed with a snare and then brought out with the biopsy forceps through that port. This specimen was sent to the Pathologist for further evaluation. The scope was brought around to the ascending colon. I could not get the scope to any further. I could not find any gross pathologic changes. The patient received an additional Demerol and Versed during the procedure to a total of 75 of Demerol and 9 of Versed. The scope was then carefully withdrawn and the puddles of fluid were evacuated as the scope was withdrawn. Good hemostasis was found at the site of the polypectomy. The scope was then carefully withdrawn. The patient tolerated the procedure reasonably well. There were no complications. The patient left the Procedure Room in stable condition. Follow up: The patient will follow up in my office in 7 to 14 days. The patient will be given a prescription for Anusol suppositories. Code(s): _____________________________