sheena91382
New
Op Note:
Pre-Op Dx: draining left groin wound
Post-op dx: draining left groin wound, scar tissue
Procedure: The patient & I pre-marked the area in question. She then was brought into the OR where she underwent IV sedation & was prepped with Chloraprep & draped in the usual sterile fashion. An appropriate time-out was held. The skin & subq tissues were anesthetized. I made an elliptical incision encompassing the previous scar & the drainage tract, which had closed over. I dissected down into the subq tissue, removing the scar tissue in totality. There was no purulence or granulation tissue at the bas of the incision. I did debride with cautery into the subq tissues. Specimen was passed off for pathology. Hemostasis was achieved. The would was closed with 2 layer Vicryl & a subq Ethilon with Steri-Strips. All counts correct at the end of the case. Estimated blood loss was minimal.
Findings: Final pathology is pending. I do not know whether the etiology was a suture granuloma or perhaps an ingrown hair.
Pathology: Skin and subq tissue from left groin, excision: scar with moderate chronic inflammation & small suture granulomata. 6x2x4cm.
Would 11042 & 11045 be correct for this?
Pre-Op Dx: draining left groin wound
Post-op dx: draining left groin wound, scar tissue
Procedure: The patient & I pre-marked the area in question. She then was brought into the OR where she underwent IV sedation & was prepped with Chloraprep & draped in the usual sterile fashion. An appropriate time-out was held. The skin & subq tissues were anesthetized. I made an elliptical incision encompassing the previous scar & the drainage tract, which had closed over. I dissected down into the subq tissue, removing the scar tissue in totality. There was no purulence or granulation tissue at the bas of the incision. I did debride with cautery into the subq tissues. Specimen was passed off for pathology. Hemostasis was achieved. The would was closed with 2 layer Vicryl & a subq Ethilon with Steri-Strips. All counts correct at the end of the case. Estimated blood loss was minimal.
Findings: Final pathology is pending. I do not know whether the etiology was a suture granuloma or perhaps an ingrown hair.
Pathology: Skin and subq tissue from left groin, excision: scar with moderate chronic inflammation & small suture granulomata. 6x2x4cm.
Would 11042 & 11045 be correct for this?
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