KaylaRieken
True Blue
On exam he does have some mild scrotal edema and edema of the penile shaft and foreskin. There is an open area of about 1 cm in the right mid lateral scrotum. Some surrounding induration and edema that encompasses an area of about 5 or 6 cm above and below this area of opening. There is some necrotic tissue in the depths of this. This was able to be debrided after administering IV 0.5 mg of Dilaudid. I did digital manipulation and fractured some loculations in the depths of this wound creating a cavity about half the size of a golf ball. There are some small draining sinus tracts about 2 or 3 in number at the more inferior aspect of the scrotum towards the perineum. There is much less induration in this area but there is some purulent drainage more consistent with a hidradenitis type picture. Is no fluctuance, necrotic skin or any sign of fluctuance or crepitus. I then packed the wound with several inches of quarter inch iodoform gauze.
Would this be 11004 or 11043? The diagnosis provider gave me in the History and Physical was Cellulitis of scrotum and Right scrotal abscess but he does state in this exam the patient has necrotic tissue. Patient is an inpatient at the hospital.
Would this be 11004 or 11043? The diagnosis provider gave me in the History and Physical was Cellulitis of scrotum and Right scrotal abscess but he does state in this exam the patient has necrotic tissue. Patient is an inpatient at the hospital.