I am new to coding so any help would be greatly appreciated.
1.Open incision and drainage of right lateral chest wall through previous thoracotomy incision.
2.Debridement of necrotic soft tissue.
3.Placement of 28-French drain.
Lung resection several months ago, developed infected thoracotomy incision which was opened and drained and had healed. Was seen as recently as 7 days ago and was doing well. Now admitted with increasing pain, shoulder pain and spontaneous drainage through midportion of that thoracotomy incision.
Patient prepped…
The area in the mid right thoracotomy incision which had spontaneously drain was excised and I opened most of that old thoracotomy incision down through the subcutaneous tissue. There were no abscesses identified and most of this drainage had spontaneously drained itself. There was some necrotic subcutaneous debris that I removed and I extended my incision down to the chest wall muscles. There were several small abscesses identified which I drained and any nonviable or infected material that I found was sharply debrided and resected. I could not find an opening into the pleural cavity anywhere and did not reopen the previous chest incision. At this point, I did make an incision low in the lateral chest, dissected under direct vision over one of the ribs into the pleural space. There was significant amount of pleural adhesions and I did not encounter any pus within the pleural cavity at that level. We did place a 28-French chest tube and sutured this to the skin. We now irrigated and then packed this wound open with Betadine Kerlix packing. Sterile dressings were then applied.
1.Open incision and drainage of right lateral chest wall through previous thoracotomy incision.
2.Debridement of necrotic soft tissue.
3.Placement of 28-French drain.
Lung resection several months ago, developed infected thoracotomy incision which was opened and drained and had healed. Was seen as recently as 7 days ago and was doing well. Now admitted with increasing pain, shoulder pain and spontaneous drainage through midportion of that thoracotomy incision.
Patient prepped…
The area in the mid right thoracotomy incision which had spontaneously drain was excised and I opened most of that old thoracotomy incision down through the subcutaneous tissue. There were no abscesses identified and most of this drainage had spontaneously drained itself. There was some necrotic subcutaneous debris that I removed and I extended my incision down to the chest wall muscles. There were several small abscesses identified which I drained and any nonviable or infected material that I found was sharply debrided and resected. I could not find an opening into the pleural cavity anywhere and did not reopen the previous chest incision. At this point, I did make an incision low in the lateral chest, dissected under direct vision over one of the ribs into the pleural space. There was significant amount of pleural adhesions and I did not encounter any pus within the pleural cavity at that level. We did place a 28-French chest tube and sutured this to the skin. We now irrigated and then packed this wound open with Betadine Kerlix packing. Sterile dressings were then applied.