Sample Name: Ischial Ulcer Debridement
Description: Debridement left ischial ulcer.
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSES: Nonhealing decubitus ulcer, left ischial region? Osteomyelitis, paraplegia, and history of spina bifida.
POSTOPERATIVE DIAGNOSES: Nonhealing decubitus ulcer, left ischial region? Osteomyelitis, paraplegia, and history of spina bifida.
PROCEDURE PERFORMED: Debridement left ischial ulcer.
ANESTHESIA: Local MAC.
INDICATIONS: This is a 27-year-old white male patient, with a history of spina bifida who underwent spinal surgery about two years ago and subsequently he has been paraplegic. The patient has a nonhealing decubitus ulcer in the left ischial region, which is quite deep. It appears to be right down to the bone. MRI shows findings suggestive of osteomyelitis. The patient is being brought to operating room for debridement of this ulcer. Procedure, indication, and risks were explained to the patient. Consent obtained.
I did not rongeur the bone. The deeper portion of the excised tissue was also sent for tissue cultures. Hemostasis was achieved with cautery and the wound was irrigated with sterile saline solution and then packed with medicated Kerlix. Sterile dressing was applied. The patient transferred to recovery room in stable condition.
Keywords: gastroenterology, debridement, ischial ulcer, ischial region, osteomyelitis, paraplegia, spina bifida, decubitus ulcer,