smweiss
New
I need help coding this op report. I am thinking maybe 10121 and 12031 or 27324??? Any help would be greatly appreciated. Thanks in advance!!!!
INDICATIONS:
The patient had undergone a right quadriceps tendon repair 2 years ago and then over the past 6mo had been developing intermittent swelling with drainage at the superior aspect of the surgical incision site. Due to concerns over infection vs suture reaction he was indicated for operative intervention and informed consent was obtained at his preop visit.
DESCRIPTION OF PROCEDURE: The patient was correctly identified in the preoperative holding area and the operative extremity was then signed by the operating surgeon. The patient was then brought to the operating room by the anesthesia service. The patient was then positioned supine with all bony prominences well padded. Anesthesia was then induced. Non sterile tourniquet placed on the operative extremity and SCD on the non-operative extremity. The operative extremity was then prepped and draped in the usual sterile fashion. Final time-out and site verification were reconfirmed.
A small partially healed ulceration in the superior aspect of the healed surgical scar was identified and then the intended incision site marked out. Then the intended incision site infiltrated with 19cc of a 1:1 mixture of 1% plain lidocaine and 0.5% plain Marcaine.
Next, incision was made thru skin and subcutaneous tissue sharply. Continued dissection thru what appeared to be scar tissued with bovie electrocautery. Small sinus tract was noted that was followed deep to the tendon repair site. Prior non absorbable suture were identified and then removed. Further exploration noted healthy appearing tissue, no purulence and no further deep suture. Quad tendon repair site was palpable and appeared intact. Next the sinus tract was excised as well. Deep culture specimens were then taken and passed off of the field. Clindamycin 600mg IV was then given.
Next the wound was irrigated out copiously. Closure was performed in layered fashion. The deep tissue layer was reapproximated with #2 Ethibond. Then the skin layer closed with 2.0 Nylon.
The incision was then dressed with Xeroform, dressing flats and sterile Webril. A hinged knee postop brace was then applied. The patient was then awakened from anesthesia and appeared to tolerate the procedure well. The patient was then transferred to APU for recovery.
Postoperative plan is for the patient to be weight bearing on the left lower extremity with hinged knee brace locked in extension. Patient will then follow up with us in 2 weeks or sooner if he has questions or concerns.
INDICATIONS:
The patient had undergone a right quadriceps tendon repair 2 years ago and then over the past 6mo had been developing intermittent swelling with drainage at the superior aspect of the surgical incision site. Due to concerns over infection vs suture reaction he was indicated for operative intervention and informed consent was obtained at his preop visit.
DESCRIPTION OF PROCEDURE: The patient was correctly identified in the preoperative holding area and the operative extremity was then signed by the operating surgeon. The patient was then brought to the operating room by the anesthesia service. The patient was then positioned supine with all bony prominences well padded. Anesthesia was then induced. Non sterile tourniquet placed on the operative extremity and SCD on the non-operative extremity. The operative extremity was then prepped and draped in the usual sterile fashion. Final time-out and site verification were reconfirmed.
A small partially healed ulceration in the superior aspect of the healed surgical scar was identified and then the intended incision site marked out. Then the intended incision site infiltrated with 19cc of a 1:1 mixture of 1% plain lidocaine and 0.5% plain Marcaine.
Next, incision was made thru skin and subcutaneous tissue sharply. Continued dissection thru what appeared to be scar tissued with bovie electrocautery. Small sinus tract was noted that was followed deep to the tendon repair site. Prior non absorbable suture were identified and then removed. Further exploration noted healthy appearing tissue, no purulence and no further deep suture. Quad tendon repair site was palpable and appeared intact. Next the sinus tract was excised as well. Deep culture specimens were then taken and passed off of the field. Clindamycin 600mg IV was then given.
Next the wound was irrigated out copiously. Closure was performed in layered fashion. The deep tissue layer was reapproximated with #2 Ethibond. Then the skin layer closed with 2.0 Nylon.
The incision was then dressed with Xeroform, dressing flats and sterile Webril. A hinged knee postop brace was then applied. The patient was then awakened from anesthesia and appeared to tolerate the procedure well. The patient was then transferred to APU for recovery.
Postoperative plan is for the patient to be weight bearing on the left lower extremity with hinged knee brace locked in extension. Patient will then follow up with us in 2 weeks or sooner if he has questions or concerns.