OP-13 Page 1 of 3 MRN Sex
Female DOB Age
50 __ __
No changes from last visit. Plan : Excision of lesion , left cheek.
Routing History …
Date/Time 05/29/2014 8:02AM
Department of Surgery
:nterval H&P Note
Division of Plastic & Reconstructive Surgery
SUBJECTIVE: Reason for request: cyst of face
Service date: 05/29/2014 8:01 AM
Service date: 05/13/2014 1:51 PM
is a 49 y.o. female who is being seen for a lesion/mass of the left cheek. She had a cyst at the site many years ago , with either excision or drainage with resulting scar. Recently , she has noticed the scar has enlarged , become itchy and at times drains foul smelling material. She is otherwise healthy.
C o mComplaint Patient presents with • New Patient
consult for facial cyst
Past Medical Histo ry Diagnosis • Hyperprolactinemia
with pituitary microadenoma • Hypothyroidism • Pituitary adenoma • Anemia
No past surgical history on file . Family History Problem
Diabetes High Cholesterol High Blood Pressure Heart Disease Cancer
breast cancer, at 77yo High Cholesterol
Relation Brother Father Father Father Mother
A g e of Onset
History _ _.·�� ·!
� .. _.,. :!�·.,.•””.” .’
Social History • Marital Status:
Spouse Name: . ..;a,�mJ:i,e.r,
,, of Children:
• Years of Education:
Occupational His1ory • Not on file.
Social History Main Topics • Smoking status: • Smokeless tobacco: • Alcohol Use:
• Drug Use: • Sexually Active:
·�·· Birth Cortf’rol/ Protection:
Other Topics • Not on file
Social Hislory Narrative
Married N/A N/A N/A
Never Smoker Never Used
, .,.;; <¥es .,,
No Yes — Male partner(s) Condom
Married, 2 kids, working in Husband
Current Outpatient Prescriptions fv1edication • levothyroxine (SYNTHROID,
LEVOTHROID) 112 MCG tablet
Sig Take 1 Tablet by mouth daily.
No current facility-administered medications for this visit.
No Known Allergies
Dispense 90 Tablet
I have updated and/or confirmed the past medical, surgical, family and social history.
Review of Systems
13 point review of systems is negative.
Page 2 of 3
BP 138/80 I Pulse 65 I Temp(Src) 36.4 °C (97.6 °F) (Oral) I Ht 1.676 m (5′ 6″) I Wt 65.772 kg (145 lb) I BMI 23.41 kg/m2
Body surface area is 1.75 meters squared.
Physical Exam: BP 138/80 I Pulse 651 Temp(Src) 36.4 °C (97.6 °F) (Oral) I Ht 1.676 m (5′ 6″) I Wt 65.772 kg (145 lb) I BMI 23.41 kg/m2 General appearance: alert, cooperative, no distress, appears stated age Head: Normocephalic, without obvious abnormality; Firm, slightly raised lesion with palpable mass of left cheek, – 1.7mm diameter. No erythema. No intraoral extension. Freely mobile. Eyes: negative Neck: supple, symmetrical, trachea midline and no adenopathy Extremities: extremities normal, atraumatic, no cyanosis or edema Skin: Skin color, texture, turgor normal. No rashes or lesions Neurologic: Grossly normal
Page 3 of3
Data Review: none
ASSESSMENT: Benign skin or soft tissue lesion, most likely inclusion cyst or similar.
PLAN: Discussed option of excision, with details provided about location, orientation and size of resulting scar. She states she has some anxiety with procedures and would like to have sedation or anesth for the case .
Plastic Surgery Discharge Summaries
Page 1 of 1
Service dale: 05/29/2014 8:08AM
__ .. .. __ .. …. .. .. .. … ..
Keep wound clean and dry. Activity as tolerated. Keep steri strips in place. Let them fall off. May Shower starting Friday afternoon, May 30. F/U as instructed. Routing History …
Date/Time 05/29/2014 8:09AM
From To Method In Basket
__ SURGEON Signed
PATIENT NAME: MRN: – DATE OF SERVICE: 05/29/2014
.. Page 1 of2
Service date: 05/29/2014 3:55PM
PREOPERATIVE DIAGNOSIS: Soft tissue and skin lesion on the left cheek measuring 1 em in diameter.
POSTOPERATIVE DIAGNOSIS: Soft tissue and skin lesion on the left cheek measuring 1 em in diameter.
OPERATION PERFORMED: Excision of lesion, 1 em, from the left lower cheek with layered closure .
SURGEON ASSISTANT SURGEON : None.
ANESTHESIOLOGIST: ASSISTANT ANESTHESIOLOGIST:
SPECIMEN: Specimen to pathology.
HISTORY: This is a woman we saw in clinic with a history and exam consistent with benign lesion of cystic nature of the left lower cheek that has been present for many years, slowly enlarging and intermittently draining . She wished to have it removed. We discussed excision, placement, and size of a resulting scar. We discussed additional risks and benefits, and after answering all questions, a signed written consent was obtained.
PROCEDURE IN DETAIL: The patient was met in Preoperative Holding. The operative site was marked. There were no new concerns. The operative plan was reviewed. The patient was brought to the Operating Room and the full team time-out was performed. The patient had lower extremity SCDs placed and turned on, and underwent general anesthesia in the supine position with abundant padding of her extremities and joints. No preoperative antibiotics were given due to the simple skin nature of this and the location of the face . The area was prepped and draped In the usual sterile fashion. A second staged time-out was performed. Preoperative markings were confirmed and oriented in a curvilinear vertica l manner to coincide with the natural crease of the inferior extension of the nasolabial crease down towards the chin , also known as the marionette lines. An elliptical-type excision was incorporated with the closure to fall within this crease . The area was infiltrated with 5 ml of 0.25% Marcaine with epinephrine. After time for a vasoconstrictive effect, the incision was carried down through the skin into the subcutaneous layer. Sharp dissection was performed to envelope any scar- appearing tissue and firm nodular tissue . The lesion was rem oved and sent off the fie ld for routine pathology examination. The area was treated with electrocautery for hemostasis and closed in 2 layers with 3-0 Monocryl and 4-0 Monocryl, Steri-Strips as a dressing. This completed the operation. A layered closure was approximately 1.4 em in length . There were no known complications . Estimated blood loss was 5 ml or less. I was present and performed the operation. The patient was awakened and taken to the Recovery Room in stable condition.
about: blank 8/13/2014
DD: 05/29/2014 11:31 DT: 05/29/2014 15:55 Job#: 360343/612667661
Last signed MD [06/01/2014 by: 6.13 PM]
.. Page 2 of2
Service: Plastic Surgery � Physicians(S) I /Surgeons
SPECIMEN(S) SUBMITTED I PROCEDURES ORDERED A. Skin and subcutaneous, left cheek lesion (88305)
Patient Name: Medical Record#:
Date of Birth: Age, Gender: 49, F Accession#: Report Type: 81 Surgical
Date Obtained: 5/29/2014 Date Received: 5/29/2014
CLINICAL HISTORY: 49 year-old Asian female with painful lesion on left face.
A. Skin and subcutaneous, left cheek lesion EPIDERMAL CYST
G ROSS DESCRIPTION: Received the following specimen(s) in the Department of Pathology, labeled with the patient’s name and hospital #
A. Skin and subcutaneous, left cheek lesion
A. The specimen is received in formalin, designated “Skin and subcutaneous, cheek lesion” and consists of an unoriented, elliptical excision of beige, slightly raised, granular skin and pink to yellow subcutaneous tissue. The specimen is 1.5 cm long by 0.5 cm wide and is excised to a depth of 1.0 cm. The incisional margins are inked blue. The specimen is serially sectioned, revealing a 0.4 cm subcutaneous cystic focus, containing yellow-tan debris. The cut surfaces of the subcutaneous tissue are otherwise fibrotic and gray-beige. The specimen is submitted entirely, as follows: A1 Tips A2 Remaining specimen, submitted entirely (5/29/2014 GRD/cdl)
A. Within the dermis there is a cyst lined with stratified squamous epithelium with epidermal keratinization and present granular layer.
“I, or my qualified designee, performed the gross examination. I have personally reviewed the gross description and performed a microscopic examination on all referenced material. I have personally issued this report on the basis of the gross and microscopic findings.”
Resident/Prosector/Pathologist: ICD9 Codes: 706.2 Diagnostic/Retrieval Codes: (5/30/2014 FDD/KFS)
Nole: Test syslems have been developed and their performance characteristics determined by Shands Medical Laboratories. Some tests have not been cleared or approved by the U.S. Food and Drug Administration. The FDA has determined that such clearance is not necessary. These tests are used for clinical purposes and should nol be regarded as invesligational or for research. This laboratory is certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA-88) as qualified to perform high complexity clinical laboratory testing.
Dermatopathologist Electronically signed 05/30/2014
ServiceDate: 5/29/2014 Acct#: · DocType: SURGICAL PATHOLOGY Report
Page 1 of 1
Medication Administration Report 1._Day 3 Days 7 Days 10 Days I_<[Today[>
Medications 05/20 05/21 05/22 o5/23 o5/24 05/25 05/26 05/27 05/28 05/29 Discontinued Medications
Medications 05/20 05/21 f 05/22 05/23 05/24 05/25 05/26 05/27 05/28 05/29 0.9 % NaCI infusion 0725 Rate: 50 mUhr Freq: CONTINUOUS Route: IV l (1,000 m L ) Start: 05/29/14 0730 End: 05/29/14 1459 acetaminophen (TYLENOL) tablet 325-650 mg ‘i Dose: 325-650 mg Freq: ONCE PRN Route: PO PRN Reason: mild pain Start: 05/29/14 0901 End: 05/29/14 1459 – Admin Instructions: Maximum acetaminophen dose from all sources is 4 grams or 75 mg/kg (whichever is less) per 24 hour period. HYDROmorphone HCI PF (DILAUDID) injection 0.5 mg Dose: 0.5 mg Freq: EVERY 5 MIN PRN Route: IV PRN Reason: other PRN Comment: For severe or breakthrough pain Start: 05/29/14 0901 End: 05/29/14 1459 – Admin Instructions: Do not exceed 5 mg per hour.
HOLD for respiratory rate less than 12 bpm, or Sp02 less than 92%, nausea/vomiting, or sleepiness. **Look- Alike I Sound- Alike Alert Use Caution** ondansetron (ZOFRAN) injection 4 mg Dose: 4 mg Freq: PRN Route: IV PRN Reason: nausea Start: 05/29/14 0901 End: 05/29/14 1459 – Admin Instructions: May repeat 1 dose if initial dose ineffective.
Ondansetron is the preferred anti-emetic; use 1st if l other anti-emetics also ordered. oxyCODONE-acetaminophen (PERCOCET) 5- 325 MG per tablet 5-10 mg Dose: 1-2 Tablet Freq: ONCE PRN Route: PO PRN Reason: moderate pain Start: 05/29/14 0901 End: 05/29/14 1459 – Admin Instructions: Maximum dose of acetaminophen is 4000 mg from all sources in 24 hours. **Look- Alike I Sound- Alike Alert, Use Caution**. Dose in mg is based on oxycodone component. Medications 05/20 05/21 05/22 05/23 05/24 05/25 05/26 05/27 05/28 05/29