Case -T5-2B OPERATIVE REPORT, ULCER EXCISION AND GRAFT

Essay

Case
-T5-2B OPERATIVE REPORT, ULCER EXCISION AND GRAFT
LOCATION: Inpatient, Hospital
PATIENT: Maynard Mortiariti
AGE: 53
SURGEON: Gary Sanchez, MD
PREOPERATIVE DIAGNOSIS: Chronic nonhealing ulcer of right lower extremity, calf
POSTOPERATIVE DIAGNOSIS: Chronic nonhealing ulcer of right lower extremity, calf
PROCEDURES PERFORMED:
1. Excision of ulcer, right lower extremity, calf.
2. Application of porcine heterograft.
SURGICAL FINDINGS:
1. A 1.5 3 cm (centimeter) open dry ulcer of the lateral aspect of the right lower extremity.
2. There was an area of purulent-appearing material at the superior periphery of the wound.
PROCEDURE: The right leg was prepped with Betadine scrub and solution and draped in routine sterile fashion. I injected about 7 cc of 1% Xylocaine with 1:100,000 epinephrine around the incision line and excised both the ulcer, measuring 4.5 sq cm, and the surrounding indurated skin, measuring 5 sq cm, with this. I encountered a pocket of purulent material that may have been either chronic infection or fat necrosis on the superior aspect of the wound. Culture and sensitivity were obtained of the tissue immediately beneath the ulcer, and Gram's stain and culture and sensitivity were obtained of the wound in the superior aspect. Pigskin was stapled to the wound, and the wound was dressed with Xeroform, Kerlix fluffs, Kerlix roll, Kling, and a short-leg Ace bandage. The patient tolerated the procedure well and left the operating room in good condition.
PATHOLOGY REPORT LATER INDICATED: Ulcerative tissue
T5-2B:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________