Gary Sanchez, M.D.
PREOPERATIVE DIAGNOSIS: Histiocytic tumor of the right shoulder
Indications: This patient is a 62-year-old gentleman that was diagnosed with a histiocytic tumor of the right shoulder and requested surgical intervention.
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Excision of plexiform fibrous histiocytic tumor of the right shoulder.
ANESTHESIA: General endotracheal with approximately 20 cc of tumescent solution prepared by adding to 1 L of Ringer's lactate, 25 cc 2% Xylocaine, 1 cc of 1:100,000 epinephrine, and 3 cc of 8.4 sodium bicarbonate.
DESCRIPTION OF PROCEDURE: The patient was intubated. The area of
the right shoulder was prepped with Betadine scrub and solution and
draped in a routine sterile fashion. An incision was made 3 cm and
carried down to the fascia of the muscle. The skin portion of the
lesion was removed, and the fascia and a portion of the muscle were
removed secondarily. The lesion measured 3.5 cm at the widest
point. Bleeding was electrocoagulated, and #7 Jackson-Pratt drain
was inserted in the depth of the wound. The wound was closed with
interrupted 0 Monocryl for the deep fascia layer and subcuticular
4-0 Monocryl using a few vertical mattress sutures of 3-0 Monocryl.
Steri-Strips and Kerlix fluffs plus Elastoplast were applied. The
patient tolerated the procedure well and left the operating room in
good condition.
Pathology Report
Later Indicated: Benign lesion.
ICD 10, CPT, HCPCS needed
CPT
Excision of plexiform fibrous histiocytic tumor of the right shoulder - CPT -25075
ICD
Histiocytic tumor of the right shoulder - D21.9
Gary Sanchez, M.D. PREOPERATIVE DIAGNOSIS: Histiocytic tumor of the right shoulder Indications: This patient is a...
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