Squamous cell carcinoma of the left forearm, 8 mm Postoperative Diagnosis
Code the following case study. Multiple codes required. Preoperative Diagnosis: Squamous cell carcinoma of the left forearm, 8 mm Postoperative Diagnosis: Squamous cell carcinoma of the left forearm, 8 mm Procedure: Excision of the .8 cm lesion with .5 cm margins on each side, layered primary closure, totaling 4 cm in length Anesthetic: Local Brief Clinical History: The patient had a biopsy-proven squamous cell carcinoma of the left forearm. After explanation of the risks, benefits, and alternatives, she agreed to re-excision and closure. She understood that there would be a scar as a result. Procedure Notes: The patient was taken to the outpatient operating area. An ellipse was taken around the primary lesion with .5-cm margins for excision around the .8 cm lesion. The area was infiltrated with 1/2% Xylocaine with 1:200,000 epinephrines and approximately 5 cc was used. The area was prepared with Betadine paint and draped in a sterile manner. The lesion was elliptically excised. After excision, the elliptical defect was closed in layers with 4-0PDS totally 4 cm in length. The deep subcutaneous layer was closed separately and then a running subcuticular layer was performed. She tolerated the procedure well. She was given instructions for local care and will return in 9 days for a checkup and suture removal.
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