SURGEON: Loren White, M.D.
PREOPERATIVE DIAGNOSES:
1. Sacral decubitus ulcer.
2. Osteomyelitis of sacrum/coccyx.
POSTOPERATIVE DIAGNOSES: Same.
PROCEDURES PERFORMED:
1. Excision of sacral ulcer.
2. Excision of coccyx.
SURGICAL FINDINGS: There was about a 4 cm deep ulcer that went all the way down to the coccyx. The coccyx was separated from the sacrum and had very sclerotic bone in it. It was very vascular around the coccyx.
ANESTHESIA: General endotracheal.
ESTIMATED BLOOD LOSS: 150 cc.
DRAINS: #10 Jackson-Pratt.
PROCEDURE: The patient was intubated and turned to the prone
position. The buttocks were prepped with Betadine scrub and
solution and draped in routine sterile fashion. The ulcer was
excised elliptically by following a hemostat to the bottom of the
wound which ended in the lower end of the sacrum/upper end of the
coccyx. We took a piece of the coccyx and placed it in a culture
tube. I then removed the coccyx which was quite vascular, clamping
bleeders with 2-0 Vicryl and putting in one stick tie of 2-0
Vicryl. The coccyx was removed and submitted for specimen. A piece
of Gelfoam with some topical thrombin spray was placed in the depth
of the wound, and the wound was closed in two layers with
interrupted 0 Monocryl for the deepest fascial layer over the drain
and over the bed from which the coccyx had been dissected. We also
closed the skin with #2 Protene. The drain was sutured in with 0
Monocryl. Dressing consisted of Kerlix fluffs and Elastoplast. The
patient tolerated the procedure well and left the operating room in
good condition.
Pathology Report Later Indicated: Benign ulcerated tissue.
ICD 10 coded, HCPCS,CPT
Procedure codes
Excision of sacral ulcer - 15931 CPT
Excision of coccyx. -15922- CPT
Dx Codes
Benign ulcerated tissue of the sacrum.-D18.01- ICD
Osteomyelitis of sacrum/coccyx. - M46.28 ICD
SURGEON: Loren White, M.D. PREOPERATIVE DIAGNOSES: 1. Sacral decubitus ulcer. 2. Osteomyelitis of sacrum/coccyx. POSTOPERATIVE DIAGNOSES:...
PREOPERATIVE DIAGNOSIS: Ischial pressure ulcer with massive ischioperineal and buttock sinus. POSTOPERATIVE DIAGNOSIS: Same. FINDINGS: There was a 2 cm open surgical ulcer extending down and connecting with an 8 × 30 cm diameter granulation-lined sinus cavity. SURGICAL PROCEDURE: Excision of left ischial ulcer with total excision of 8 × 30 cm sinus of the buttock, perineal, and ischial areas. ANESTHESIA: General endotracheal. ESTIMATED BLOOD LOSS: 400 ml. FLUIDS: 2 liters Ringer’s lactate. DRAINS: None. COMPLICATION: None. SPONGE AND NEEDLE...
Gary Sanchez, M.D. PREOPERATIVE DIAGNOSIS: Histiocytic tumor of the right shoulder Indications: This patient is a 62-year-old gentleman that was diagnosed with a histiocytic tumor of the right shoulder and requested surgical intervention. POSTOPERATIVE DIAGNOSIS: Same PROCEDURE PERFORMED: Excision of plexiform fibrous histiocytic tumor of the right shoulder. ANESTHESIA: General endotracheal with approximately 20 cc of tumescent solution prepared by adding to 1 L of Ringer's lactate, 25 cc 2% Xylocaine, 1 cc of 1:100,000 epinephrine, and 3 cc of...
PATIENT: Andy Hall SURGEON: Gary Sanchez, M.D. PREOPERATIVE DIAGNOSES: Right carotid stenosis POSTOPERATIVE DIAGNOSIS: Same. PROCEDURE PERFORMED: Right carotid thromboendarterectomy. This patient was monitored with EEG. There were some depressions when we clamped, but this returned to normal after re-establishing circulation. ANESTHESIA: General DESCRIPTION OF PROCEDURE: Under general anesthesia, the patient’s right side of the neck was prepped and draped in the usual manner. An incision was made across the medial border of the sternocleidomastoid. The platysma was divided. The...
LOCATION: Inpatient, Hospital PATIENT: Charlene Tipton SURGEON: Loren White, M.D. PRE/POSTOPERATIVE DIAGNOSIS: Right breast mass. PROCEDURE(S) PERFORMED: Right breast open biopsy. ANESTHESIA: General endotracheal. INDICATIONS: Charlene is a 66-year-old female who presented with a palpable right breast mass. A biopsy was done which showed atypical cells and was felt to be suspicious for cancer. She also had a highly suspicious lesion on ultrasound in the same area. An open biopsy was recommended. Possible definitive treatment with simple mastectomy was also...
LOCATION: Inpatient, Hospital PATIENT: Karla Stevens SURGEON: John Hodgson, M.D. PREOPERATIVE DIAGNOSES: 1. Spinal stenosis, without neurogenic claudication. 2. Spondylolisthesis, L4-L5. 3. Right radicular pain L5 root. INDICATIONS: Karla is a 52-year-old woman who is a baker and stands on her feet for many hours a day. She was diagnosed with spinal stenosis and spondylolisthesis and continues to have low back pain. She understands the risks and potential complications and problems that may occur from the surgery and wishes to...