The patient is a 72 YO male with a known malignant melanoma…
The patient is a 72 YO male with a known malignant melanoma of the right heel, with no metastasis. He is being seen today for removal of the melanoma. The patient is also known to have HTN that is well-controlled with a reading of 130/75 today; DM, type 1 that is well controlled on injectable insulin, chronic asthma that is well-controlled, and he smokes 1 PPD of cigarettes. He does have a history of heart attack in the past, and he takes Coumadin on a daily basis; however, this has been held for 5 days leading up to the surgery. PREOPERATIVE DIAGNOSIS: 1.5 cm malignant melanoma, right heel POSTOPERATIVE DIAGNOSIS: Same OPERATION: Wide local excision with split thickness skin graft from the left thigh ANESTHESIA: Spinal INDICATIONS: This 72-year-old patient has a 1.5 cm malignant lesion of the left heel. He agreed to a wide local excision. PROCEDURE: The patient was taken to the operating room, prepped and draped in the usual sterile fashion. A split-thickness skin graft (7 cm × 7 cm, thickness .05 in) was harvested from the left thigh and preserved. Next, the lesion, which was on the medial aspect of the right heel, was excised with 2.5 cm margins down to and including some of the plantar fascia. Total excised diameter was 6.5 cm. Hemostasis was achieved with 2-0 Ti-Cron sutures and the cautery. After suitable hemostasis was obtained, the wound margins were advanced with interrupted sutures of 2-0 chromic, and then the skin graft was placed. The skin graft was approximated to the skin using interrupted running sutures of 4-0 chromic, and then holes were punched in the skin graft to permit egress of serous fluid. Then, a bolster dressing of cotton batting wrapped in Owens gauze was placed over the skin graft site and secured to the skin with multiple sutures tied over it to 2-0 Ti-Cron. The skin graft donor site was wrapped with Owens gauze and two moistened ABD pads and wrapped with a Kerlix and an Ace wrap. The patient tolerated the procedure well and was transported awake and alert to the recovery room in excellent condition. First-Listed Diagnosis: Diagnosis: Diagnosis: Diagnosis: Diagnosis: Diagnosis: Diagnosis: First-Listed Procedure: Procedure: Hint: NO extra blanks. Hint: For the procedures—code the GRAFT as first-listed! Think about the 2nd procedure, do you think it needs a modifier? It is NOT 51
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