KristieStokesCPC
Expert
Op note:
OPERATIVE INDICATIONS: Mr. X is a 45-year-old male with a history of hypertension and coronary disease, underwent right tarsal tunnel release on 03/22/2012. In the postoperative period, the patient's experienced a postop hematoma that subsequently became infected and was treated with oral antibiotics and conservative local wound care. This failed because he had two areas that had delayed wound healing. Subsequently, a decision was made to take him to the operating room to debride the skin and subcutaneous tissue. On physical exam, the patient was nontoxic comfortable male and the right medial malleolar incision reveals two zones of wound infection, one measured 3.5 cm x 2 mm and the other 1.9 cm x 4 mm. The foot was warm, 2+ dorsalis pedis pulse, and 2+ posterior tibial pulse. The patient was able to actively extend and flex his great toe.
OPERATIVE PROCEDURE: After discussing risks, benefits, indications, and alternatives, the right post tarsal tunnel incision was marked to the preop area. The patient was taken to the operating room and placed in the supine position on the operating room table. EKG lead, blood pressure cuff, and pulse oximeter was placed on the patient. IV antibiotics were not administered to the patient because of the procedure. General anesthesia was achieved. The right leg was prepped and draped with Betadine. An intraoperative time-out was performed and then the distal tibial nerve block was performed using 1% lidocaine with epinephrine. Then, the wound measuring 3.5 cm in length that was excised and sent off to lab. The cultures were obtained anaerobic, aerobic, and fungal cultures from both wounds. The second incision that was measured 1.9 cm in length was also excised and the subcutaneous tissue was debrided with a curette and 9 liters of normal saline. The deeper tissue did not look infected. Therefore, there was no need for debridement. The medial and lateral adipocutaneous flaps were created and the wound was closed using 3-0 nylon interrupted horizontal mattress and 4-0 nylon in an interrupted fashion. The patient was placed in a Robert Jones dressing and awakened from the operating room table and transferred to the recovery room.
POSTOPERATIVE PLAN: The plan is for the patient to be partial weightbearing, right leg using a walker to ambulate for the first two weeks and immediate range of motion at the right hip, knee, and toes, deep breathing exercises, keep the right leg elevated and oxycodone 15 mg for postop pain. I will see the patient in two weeks to take the dressing down and three weeks for suture removal.
code: 10180 or 11042?
Thanks for any help!
OPERATIVE INDICATIONS: Mr. X is a 45-year-old male with a history of hypertension and coronary disease, underwent right tarsal tunnel release on 03/22/2012. In the postoperative period, the patient's experienced a postop hematoma that subsequently became infected and was treated with oral antibiotics and conservative local wound care. This failed because he had two areas that had delayed wound healing. Subsequently, a decision was made to take him to the operating room to debride the skin and subcutaneous tissue. On physical exam, the patient was nontoxic comfortable male and the right medial malleolar incision reveals two zones of wound infection, one measured 3.5 cm x 2 mm and the other 1.9 cm x 4 mm. The foot was warm, 2+ dorsalis pedis pulse, and 2+ posterior tibial pulse. The patient was able to actively extend and flex his great toe.
OPERATIVE PROCEDURE: After discussing risks, benefits, indications, and alternatives, the right post tarsal tunnel incision was marked to the preop area. The patient was taken to the operating room and placed in the supine position on the operating room table. EKG lead, blood pressure cuff, and pulse oximeter was placed on the patient. IV antibiotics were not administered to the patient because of the procedure. General anesthesia was achieved. The right leg was prepped and draped with Betadine. An intraoperative time-out was performed and then the distal tibial nerve block was performed using 1% lidocaine with epinephrine. Then, the wound measuring 3.5 cm in length that was excised and sent off to lab. The cultures were obtained anaerobic, aerobic, and fungal cultures from both wounds. The second incision that was measured 1.9 cm in length was also excised and the subcutaneous tissue was debrided with a curette and 9 liters of normal saline. The deeper tissue did not look infected. Therefore, there was no need for debridement. The medial and lateral adipocutaneous flaps were created and the wound was closed using 3-0 nylon interrupted horizontal mattress and 4-0 nylon in an interrupted fashion. The patient was placed in a Robert Jones dressing and awakened from the operating room table and transferred to the recovery room.
POSTOPERATIVE PLAN: The plan is for the patient to be partial weightbearing, right leg using a walker to ambulate for the first two weeks and immediate range of motion at the right hip, knee, and toes, deep breathing exercises, keep the right leg elevated and oxycodone 15 mg for postop pain. I will see the patient in two weeks to take the dressing down and three weeks for suture removal.
code: 10180 or 11042?
Thanks for any help!