sheena91382
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I need opinions on coding for this op note:
Pre-Op Dx: Persistent wound granuloma fistula.
Post-Op Dx: Persistent wound granuloma fistula.
Procedure: I&D previous appendectomy wound in the RLQ w/ debridement of subq tissue & rectus muscle.
Brief Note: The patient has had persistent drainage from an open appendectomy wound from many months ago. The would had closed over, but continuously opens up with drainage and granulation tissue in the medial aspect. This has been treated conservatively w/o success and therefore, the patient is brought to the OR for wound exploration.
Procedure: After achievement of IV sedation, the patient was prepped with Chloraprep & draped in the usual sterile fashion. An appropriate time-out was held. The skin and subq tissues were anesthetized at the medial aspect of the appendectomy wound. An elliptical incision was made encompassing the area in question w/ the previous scar. Dissection was carried down around this tissue and superficial Prolene suture was also involved in this situation. I removed that. This was all passes off for specimen. The wound was irrigated copiously and clear. At no point did I see any purulence. I closed the anterior rectus fascia with 2-0 Vicryl sutures, subq tissues w/ Vicryl suture, and the skin with Steri-Strips.
Of Note, the size of the incision was 5cm, depth was also 5cm, and width was 3cm
Pathology: Acute & chronic inflammation with focal granulation tissue, few multinucleated foreign body-type giant cells, focal necrosis, and fibrosis. Foreign material consistent with suture grossly identified in association with specimen.
Pre-Op Dx: Persistent wound granuloma fistula.
Post-Op Dx: Persistent wound granuloma fistula.
Procedure: I&D previous appendectomy wound in the RLQ w/ debridement of subq tissue & rectus muscle.
Brief Note: The patient has had persistent drainage from an open appendectomy wound from many months ago. The would had closed over, but continuously opens up with drainage and granulation tissue in the medial aspect. This has been treated conservatively w/o success and therefore, the patient is brought to the OR for wound exploration.
Procedure: After achievement of IV sedation, the patient was prepped with Chloraprep & draped in the usual sterile fashion. An appropriate time-out was held. The skin and subq tissues were anesthetized at the medial aspect of the appendectomy wound. An elliptical incision was made encompassing the area in question w/ the previous scar. Dissection was carried down around this tissue and superficial Prolene suture was also involved in this situation. I removed that. This was all passes off for specimen. The wound was irrigated copiously and clear. At no point did I see any purulence. I closed the anterior rectus fascia with 2-0 Vicryl sutures, subq tissues w/ Vicryl suture, and the skin with Steri-Strips.
Of Note, the size of the incision was 5cm, depth was also 5cm, and width was 3cm
Pathology: Acute & chronic inflammation with focal granulation tissue, few multinucleated foreign body-type giant cells, focal necrosis, and fibrosis. Foreign material consistent with suture grossly identified in association with specimen.