OPERATIVE REPORT
PRE-OPERATIVE DIAGNOSIS: Penile adhesions.
POST-OPERATIVE DIAGNOSIS: Penile adhesions.
PROCEDURE: Lysis of adhesions.
INDICATIONS: This 36-year-old male patient presented with approximately 15 adhesions between the underside of the foreskin and the glans penis. Most of the right side of the glans penis is involved with adhesions. The patient requested definitive treatment for these adhesions and does not wish to pursue circumcision. The risks, complications, and alternatives to this procedure were discussed with the patient. The patient has chosen lysis of these adhesions and presents now for this definitive surgery.
PROCEDURE: After general anesthesia was accomplished and the patient placed in the appropriate position with surgical draping, the area was prepped with Betadine and the adhesions are lysed with the cautery. Upon completion of the lysis of 15 adhesions, the penis was inspected with the appearance being excellent. The procedure was concluded with application of 5% Xyloacaine ointment being applied to the surgical area. The patient was taken to the recovery room in satisfactory condition.
ICD-9-CM diagnosis code(s): _____________________
ICD-10-CM diagnosis code(s): _____________________
CPT code(s) with modifier, if applicable: _____________________
NANDA international nursing diagnosis 1
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