Medical Specialty:

Sample Name: I&D - Buttock Abscess

Description: Incision and drainage (I&D) of buttock abscess.
(Medical Transcription Sample Report)

PRINCIPAL DIAGNOSIS: Buttock abscess, ICD code 682.5.

PROCEDURE PERFORMED: Incision and drainage (I&D) of buttock abscess.

CPT CODE: 10061.

DESCRIPTION OF PROCEDURE: Under general anesthesia, skin was prepped and draped in usual fashion. Two incisions were made along the right buttock approximately 5 mm diameter. Purulent material was drained and irrigated with copious amounts of saline flush. A Penrose drain was placed. Penrose drain was ultimately sutured forming a circular drain. The patient's drain will be kept in place for a period of 1 week and to be taken as an outpatient basis. Anesthesia, general endotracheal anesthesia. Estimated blood loss approximately 5 mL. Intravenous fluids 100 mL. Tissue collected. Purulent material from buttock abscess sent for usual cultures and chemistries. Culture and sensitivity Gram stain. A single Penrose drain was placed and left in the patient. Dr. X attending surgeon was present throughout the entire procedure.

Keywords: surgery, incision and drainage, purulent material, penrose drain, buttock abscess, i&d, drainage,