Sample Type / Medical Specialty: Surgery
Sample Name: I&D - Perirectal Abscess
Perirectal abscess. Incision and drainage (I&D) of perirectal abscess.
(Medical Transcription Sample Report)
Perirectal abscess.POSTOPERATIVE DIAGNOSIS:
Incision and drainage (I&D) of perirectal abscess.DESCRIPTION OF PROCEDURE:
The patient was taken to the operating room after obtaining an informed consent. A spinal anesthetic was given, and then the patient in the jackknife position had his gluteal area prepped and draped in the usual fashion.
Prior to prepping, I performed a digital rectal examination that showed no pathology and then I proceeded to insert an anoscope. I found some small internal hemorrhoids and no fistulous tracts.
Then, the patient was prepped and draped in the usual fashion and the abscess area, which was in the left gluteal side, was incised with a cruciate incision and drained. All necrotic tissue was debrided. The cavity was digitally explored and found to have no communication to any deeper structures or to the colorectal area. The cavity was irrigated with saline and then was packed with iodoform gauze and dressed.
Estimated blood loss was minimal. The patient tolerated the procedure well and was sent for recovery in satisfactory condition.
surgery, hemorrhoids, incision and drainage, perirectal abscess, cavity, i&d, perirectal,
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