Sample Type / Medical Specialty: Surgery
Sample Name: Wound Closure & Debridement - Hydrocephalus
A complex closure and debridement of wound. The patient is a 26-year-old female with a long history of shunt and hydrocephalus presenting with a draining wound in the right upper quadrant, just below the costal margin that was lanced by General Surgery and resolved; however, it continued to drain.
(Medical Transcription Sample Report)
TITLE OF OPERATION:
A complex closure and debridement of wound.INDICATION FOR SURGERY:
The patient is a 26-year-old female with a long history of shunt and hydrocephalus presenting with a draining wound in the right upper quadrant, just below the costal margin that was lanced by General Surgery and resolved; however, it continued to drain. There is no evidence of fevers. CRP was normal. Shunt CT were all normal. The thought was he has insidious fistula versus tract where recommendation was for excision of this tract.PREOP DIAGNOSIS:
Possible cerebrospinal fluid versus wound fistula.POSTOP DIAGNOSIS:
Possible cerebrospinal fluid versus wound fistula.PROCEDURE DETAIL:
The patient was brought to the operating room and willing to be inducted with a laryngeal mask airway, positioned supine and the right side was prepped and draped in the usual sterile fashion. Next, working on the fistula, this was elliptically excised. Once this was excised, this was followed down to the fistulous tract, which was completely removed. There was no CSF drainage. The catheter was visualized, although not adequately properly. Once this was excised, it was irrigated and then closed in multiple layers using 3-0 Vicryl for the deep layers and 4-0 Caprosyn and Indermil with a dry sterile dressing applied. The patient was reversed, extubated and transferred to the recovery room in stable condition. Multiple cultures were sent as well as the tracts sent to Pathology. All sponge and needle counts were correct.
surgery, debridement of wound, shunt, costal margin, cerebrospinal fluid, cerebrospinal, closure, debridement, hydrocephalus, draining, fistula, wound,
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