toria11
Guru
Hello! How would you code the following? I was thinking 11042 for the debridement but then read it may not include genitalia.. Thank you!
POSTOPERATIVE DIAGNOSIS:
1. Chronic ulcerative scrotal lesion.
2. Humira-related psoriasis.
PROCEDURE PERFORMED:
Scrotal wound debridement and incisional biopsy.
ANESTHESIA:
MAC and local.
PATHOLOGY:
Incisional biopsy of ulcerative scrotal wound.
INDICATIONS:
The patient is a 23-year-old male, with history of ulcerative colitis, previously treated with Humira. He developed psoriasis apparently as a side effect of the Humira. He eventually developed an ulcerative scrotal lesion over the past three months, which has been weeping and bleeding intermittently. There is severe associated pain. He presented to the hospital for the second time last week and was admitted for further evaluation. Scrotal ultrasound and CT scan of the abdomen and pelvis were performed and reviewed personally by me including the images. No signs of intrascrotal inflammation or abscess. The patient has been under the care of a dermatologist. A biopsy has not yet been done. I discussed the case with the hospitalist and both agreed to proceed with biopsy while inpatient in hopes to arrive at a definitive diagnosis for scrotal wound, the etiology which is unclear at this time.
FINDINGS:
The patient had an ulcerative scrotal lesion with granulation tissue and healthy skin edges extending from the right lateral scrotum all the way over to the left lateral scrotum in the dependent portion, but sparing the most posterior portion of the scrotum and the anterior scrotum. Depth of the wound is to the muscle, but not beyond. None of the scrotal contents were exposed. No signs of necrotic tissue in the base of the wound or along the skin edges. There were skin bridges still intact in the center of the ulcerative lesion.
DESCRIPTION OF PROCEDURE:
The patient was taken to the operating room and positively identified as well as the site of surgery during a time-out. After adequate MAC anesthesia, he was transferred into the modified dorsal lithotomy position, and prepped and draped in the usual sterile fashion. His scrotal wound was then irrigated with copious amounts of sterile saline and debrided with a wet lap pad. Overlying exudate was cleared. This revealed healthy granulation tissue in the bed of the ulcerative lesion and wound edges. There are a few areas of skin bridges in the center of the ulcerative wound. The wound borders were as described above in the findings. The wound stopped at the depth of the muscle. None of the scrotal contents were exposed. An incisional biopsy was performed in the superior mid portion of the wound to include two areas of skin bridges. The granulating base of the wound was not incised out of concern for potential difficulty with wound healing and hemostasis. Biopsy sites were fulgurated and hemostasis obtained with electrocautery. The wound was then bathed with Marcaine with epinephrine. Circumferential infiltration with Marcaine with epinephrine was performed in hopes to provide some pain control. The patient then had a dressing applied by the wound care nurses in the operating room. He tolerated the procedure well without complications. JR 20211202
POSTOPERATIVE DIAGNOSIS:
1. Chronic ulcerative scrotal lesion.
2. Humira-related psoriasis.
PROCEDURE PERFORMED:
Scrotal wound debridement and incisional biopsy.
ANESTHESIA:
MAC and local.
PATHOLOGY:
Incisional biopsy of ulcerative scrotal wound.
INDICATIONS:
The patient is a 23-year-old male, with history of ulcerative colitis, previously treated with Humira. He developed psoriasis apparently as a side effect of the Humira. He eventually developed an ulcerative scrotal lesion over the past three months, which has been weeping and bleeding intermittently. There is severe associated pain. He presented to the hospital for the second time last week and was admitted for further evaluation. Scrotal ultrasound and CT scan of the abdomen and pelvis were performed and reviewed personally by me including the images. No signs of intrascrotal inflammation or abscess. The patient has been under the care of a dermatologist. A biopsy has not yet been done. I discussed the case with the hospitalist and both agreed to proceed with biopsy while inpatient in hopes to arrive at a definitive diagnosis for scrotal wound, the etiology which is unclear at this time.
FINDINGS:
The patient had an ulcerative scrotal lesion with granulation tissue and healthy skin edges extending from the right lateral scrotum all the way over to the left lateral scrotum in the dependent portion, but sparing the most posterior portion of the scrotum and the anterior scrotum. Depth of the wound is to the muscle, but not beyond. None of the scrotal contents were exposed. No signs of necrotic tissue in the base of the wound or along the skin edges. There were skin bridges still intact in the center of the ulcerative lesion.
DESCRIPTION OF PROCEDURE:
The patient was taken to the operating room and positively identified as well as the site of surgery during a time-out. After adequate MAC anesthesia, he was transferred into the modified dorsal lithotomy position, and prepped and draped in the usual sterile fashion. His scrotal wound was then irrigated with copious amounts of sterile saline and debrided with a wet lap pad. Overlying exudate was cleared. This revealed healthy granulation tissue in the bed of the ulcerative lesion and wound edges. There are a few areas of skin bridges in the center of the ulcerative wound. The wound borders were as described above in the findings. The wound stopped at the depth of the muscle. None of the scrotal contents were exposed. An incisional biopsy was performed in the superior mid portion of the wound to include two areas of skin bridges. The granulating base of the wound was not incised out of concern for potential difficulty with wound healing and hemostasis. Biopsy sites were fulgurated and hemostasis obtained with electrocautery. The wound was then bathed with Marcaine with epinephrine. Circumferential infiltration with Marcaine with epinephrine was performed in hopes to provide some pain control. The patient then had a dressing applied by the wound care nurses in the operating room. He tolerated the procedure well without complications. JR 20211202