How would i code this op report?

lindafay1123

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OPERATIVE REPORT
SURGEON: DR. A
PREOPERATIVE DIAGNOSES:
1. Upper back mass.
2. Multiple ulcers, left lower extremity.
POSTOPERATIVE DIAGNOSES:
1. Upper back mass.
2. Multiple ulcers, left lower extremity.
PROCEDURE:
1. Excision of back mass size measuring approximately 4 x 3
cm to the level of the deep muscle.
2. Excisional debridement of 4 wounds in the left lower
extremity with skin biopsies x3.

ANESTHESIA: Monitored anesthesia care.

TECHNIQUE: The patient was admitted to the operating table in
the supine position. Once sedation and monitoring were
established by the anesthesiologist, she was rolled in the
left lateral decubitus position. The back mass which was just
inferior to the scapula was reidentified. It measured
approximately 4 x 3 cm. Transverse incision was made
approximately 4 cm long, carried down to a back mass that was
stuck to the deep muscle and to the chest wall. This was a
highly vascular mass, it was stuck to the muscle. I did a
wide excision around this with grossly negative margins.
There was still some oozing from the muscle bed and this was
cauterized and then Surgicel was placed. The back mass was
sent for permanent sections. The wound was then closed using
interrupted 3-0 nylon stitches. A pressure dressing was then
applied.
The left lower extremity area was then prepped and draped in
a sterile fashion. There was noted to be 4 wounds, there was
a 4 x 3 cm superior wound on the leg, this was anterior.
There was one just inferior to this that measured 5 x 3 cm on
the anterior leg. The medial malleolus had a wound that
measured 3 x 2 cm and a lateral wound with irregular margins
that measured approximately 7 x 3 cm. The depth was all
approximately 0.1-0.2 cm.
These areas were anesthetized. Skin biopsies were taken for
microbiology which included aerobic, anaerobic, and fungal.
Skin biopsies were taken for vasculitis profile x2. Following
this, then the wounds were surgically debrided to the level
of the muscle. These wounds were all debrided to the muscle
and all the slough was removed until there was a bleeding
granulating base. These were then irrigated with liters of
normal saline.
At the conclusion, hemostasis was adequate. Hydrogel was
placed into the wound bed then followed by Adaptic, Kerlix
wrap and an Ace wrap. The patient did tolerate the procedure
well. She awoke in the operating room and returned to
recovery in stable condition. All instrument and sponge
counts were correct.
 
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