rkindlund
Networker
I cannot find a code that seems to fit what my surgeon did here. Any input would be appreciated. Any exploration codes require foreign body removal, and I&D requires drainage by definition, which was not done.
NAME OF PROCEDURE: Left upper extremity incision exploration and culture x 2.
HISTORY OF PRESENT ILLNESS: This is a 60-year-old gentleman from San Juan
Island who developed onset of left upper extremity cellulitis, was admitted to
the hospital on the 27th and was placed on antibiotics. Ultrasound showed edema
within the tissues, no fluid collections. Since the admission, he has had
increasing left upper extremity discomfort and progressive cellulitis. Some of
the skin shows small bullae and CT scan indicates extensive edema as does
physical examination. Because of concerns of necrotizing fasciitis or undrained
fluid collection, the patient was taken urgently to the operative suite for
exploration.
DESCRIPTION OF PROCEDURE: The patient was placed in supine position undergoing
general anesthetic. He was sterilely prepped and draped over the left upper
extremity. An initial incision is made along the medial forearm, midway between
the olecranon and wrist. It was made in a longitudinal fashion for
approximately 4 to 5 cm. Upon entering the skin, there is a hemorrhage at all
levels of tissue. The lipomatous layer was divided with electrocautery down to
the level of fascia, which is intact, viable without evidence of purulence nor
undrained fluid collection. Cultures were obtained in the deep subcutaneous
tissue and overlying the fascia and sent for evaluation. Hemostasis was
achieved with electrocautery. Closure was performed with a deep layer of
interrupted 3-0 Vicryl sutures and the skin was approximated with 3-0 nylon
vertical mattress sutures.
Attention was then turned towards the upper arm. On the posterior aspect of the
brachium at its midportion, a longitudinal incision was made for 4 cm. Again,
hemorrhage is noted at the level of the skin. No purulence is identified. The
subcutaneous layer is grossly edematous, but without evidence of fasciitis. The
muscle is soft without compartment syndrome and all levels of tissue including
dermis, subcutaneous tissue and fascial layer are hemorrhagic and bleed freely.
Hemostasis was achieved with electrocautery. Veins in the subcutaneous tissue
are patent. Closure was performed with a deep interrupted layer of 3-0 Vicryl
sutures and the skin was approximated with 3-0 nylon vertical mattress sutures.
Total blood loss was 25 mL. The patient tolerated the procedure well. The
wounds were covered with Xeroform gauze and absorptive dressing and Kerlix.
NAME OF PROCEDURE: Left upper extremity incision exploration and culture x 2.
HISTORY OF PRESENT ILLNESS: This is a 60-year-old gentleman from San Juan
Island who developed onset of left upper extremity cellulitis, was admitted to
the hospital on the 27th and was placed on antibiotics. Ultrasound showed edema
within the tissues, no fluid collections. Since the admission, he has had
increasing left upper extremity discomfort and progressive cellulitis. Some of
the skin shows small bullae and CT scan indicates extensive edema as does
physical examination. Because of concerns of necrotizing fasciitis or undrained
fluid collection, the patient was taken urgently to the operative suite for
exploration.
DESCRIPTION OF PROCEDURE: The patient was placed in supine position undergoing
general anesthetic. He was sterilely prepped and draped over the left upper
extremity. An initial incision is made along the medial forearm, midway between
the olecranon and wrist. It was made in a longitudinal fashion for
approximately 4 to 5 cm. Upon entering the skin, there is a hemorrhage at all
levels of tissue. The lipomatous layer was divided with electrocautery down to
the level of fascia, which is intact, viable without evidence of purulence nor
undrained fluid collection. Cultures were obtained in the deep subcutaneous
tissue and overlying the fascia and sent for evaluation. Hemostasis was
achieved with electrocautery. Closure was performed with a deep layer of
interrupted 3-0 Vicryl sutures and the skin was approximated with 3-0 nylon
vertical mattress sutures.
Attention was then turned towards the upper arm. On the posterior aspect of the
brachium at its midportion, a longitudinal incision was made for 4 cm. Again,
hemorrhage is noted at the level of the skin. No purulence is identified. The
subcutaneous layer is grossly edematous, but without evidence of fasciitis. The
muscle is soft without compartment syndrome and all levels of tissue including
dermis, subcutaneous tissue and fascial layer are hemorrhagic and bleed freely.
Hemostasis was achieved with electrocautery. Veins in the subcutaneous tissue
are patent. Closure was performed with a deep interrupted layer of 3-0 Vicryl
sutures and the skin was approximated with 3-0 nylon vertical mattress sutures.
Total blood loss was 25 mL. The patient tolerated the procedure well. The
wounds were covered with Xeroform gauze and absorptive dressing and Kerlix.