Date of Surgery -
Preop Diagnosis - wound/abscess
Postop Diagnosis - same
Surgeon - Dr. Luk / Dr. Tran
Anesthesia - General
Blood Loss - Minimal
Complication - None
Findings - abscess
Specimens - tissue send tor pathology and culture obtained
Procedure Performed:
Debridement of Wound/Abscess of complex wound requiring post operative packing
The patient was seen in consultation. Surgery is recommended for debridement of the wound.
Patient comes in with the above diagnosis and was consented for the above procedures. Risks, benefits, and alternatives were discussed with patient, which includes, but are not limited to, postoperative or chronic pain, bleeding, wound infection, hematoma, post-operative abscess, injury to other organs, or need for further procedures or workup. Other Complications may include deep vein thrombosis(blood clots), as well as other side effects affecting other organ systems such as the heart or lungs, and in rare circumstances, death as a result of the above complications. The patient is also informed that the wound may have to be left open for dressing changes and allowed for secondary healing.
The patient understands and agrees to proceed with the proposed procedure.
The patient was given preoperative antibiotics
Location:
Type: Sharp with scalpel and electrocautery
Length: cm
Width: cm
Depth: The debridement was carried to .......
Patient brought back to OR. Time out was performed. Anesthesia was applied with no complication. The Scalpel was used for the skin incision. Size and extend of the debridement are as above. Excisional debridement was performed to healthy tissue.
At the end of the case, counts were carried out. When instrument, sponge, and needle
counts were completed and reported to me as correct, then I began the closure/packing of the wound
Wound Cavity Washout out with copious saline. Wound packed for post operative continued care with moist to dry dressing and expectant secondary healing
Hemostasis was obtained, Patient tolerated procedure well. Was transferred to recovery in stable and satisfactory condition.