Sample Name: Abdominal Abscess I&D
Description: Incision and drainage (I&D) of abdominal abscess, excisional debridement of nonviable and viable skin, subcutaneous tissue and muscle, then removal of foreign body.
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Abdominal wall abscess.
POSTOPERATIVE DIAGNOSIS: Abdominal wall abscess.
PROCEDURE: Incision and drainage (I&D) of abdominal abscess, excisional debridement of nonviable and viable skin, subcutaneous tissue and muscle, then removal of foreign body.
INDICATIONS: Patient is a pleasant 60-year-old gentleman, who initially had a sigmoid colectomy for diverticular abscess, subsequently had a dehiscence with evisceration. Came in approximately 36 hours ago with pain across his lower abdomen. CT scan demonstrated presence of an abscess beneath the incision. I recommended to the patient he undergo the above-named procedure. Procedure, purpose, risks, expected benefits, potential complications, alternatives forms of therapy were discussed with him, and he was agreeable to surgery.
TECHNIQUE: Patient was identified, then taken into the operating room, where after induction of appropriate anesthesia, his abdomen was prepped with Betadine solution and draped in a sterile fashion. The wound opening where it was draining was explored using a curette. The extent of the wound marked with a marking pen and using the Bovie cautery, the abscess was opened and drained. I then noted that there was a significant amount of undermining. These margins were marked with a marking pen, excised with Bovie cautery; the curette was used to remove the necrotic fascia. The wound was irrigated; cultures sent prior to irrigation and after achievement of excellent hemostasis, the wound was packed with antibiotic-soaked gauze. A dressing was applied. The finished wound size was 9.0 x 5.3 x 5.2 cm in size. Patient tolerated the procedure well. Dressing was applied, and he was taken to recovery room in stable condition.
Keywords: gastroenterology, excisional debridement, subcutaneous tissue, abdominal wall abscess, foreign body, abdominal abscess, bovie cautery, abdominal, i&d, wound, incision, abscess,