Assignment Task:
LOCATION: Inpatient, Hospital
PATIENT: Arnold Rolf
SURGEON: Gary Sanchez, MD
INDICATIONS FOR THIS PROCEDURE: This patient has had an apparent full-thickness loss of an area of previous surgery overlying the medial aspect of the left lower tibia. The patient sustained a compound tibial fracture 2 months previously, and this was immediately plated by Dr. Almaz. The patient subsequently developed a full-thickness loss in this area, and I saw him last week in an attempt to try to dry this area out and possibly salvage any tissue overlying the plate. When he was seen in the office, I felt he probably had a full-thickness loss and scheduled him for debridement. The patient was not set up at this time for soleus muscle flap, although that has been discussed as the possible definitive management, although it is slightly low for a soleus muscle flap. The only other alternative is a free flap.
PREOPERATIVE DIAGNOSIS: Full-thickness tissue loss, left lower extremity, medial aspect of lower third of leg. (This is an ulcer.)
POSTOPERATIVE DIAGNOSIS: Full-thickness tissue loss, left lower extremity, medial aspect of lower third of leg.
PROCEDURE PERFORMED: Debridement of soft tissue of left lower extremity, and culture and sensitivity of two deep soft-tissue sites and two bone sites, with the fourth bone site being from the medullary cavity.
ANESTHESIA: General endotracheal
SURGICAL FINDINGS: A 3-cm (centimeter)-diameter, full-thickness skin loss overlying a previously plated fracture. Lying on top of the plate and overlying two of the plate holes was a liquefactive (conversion to liquid) necrotic area. In one of the holes for the plate, there was some cloudy drainage of which we obtained a culture and sensitivity. We also obtained culture and sensitivity of another deep soft-tissue site and the other hole in the tibia in conjunction with the plate. There were actually loose bone particles in this area. We debrided 20 sq. cm. of bone.
PROCEDURE: The patient's left leg was prepped with Betadine scrub and solution and draped in a routine sterile fashion. We lifted up the eschar (slough produced by a heat burn) with sharp dissection and noted there was liquefactive necrosis underneath the eschar and actually lying on top of the plate. We took some of the tissue from underneath the eschar on its deep surface and placed this for culture and sensitivity, labeling it "deep tissue with eschar, left lower extremity." Number two was also labeled "deep tissue over plate." Specimen number three was labeled "culture and sensitivity of bone and tissue." Number four was labeled "bone from medullary cavity, left tibia." After we obtained these cultures, we placed Xeroform on the wound and put a 4 × 4 over this. We wrapped it with a Kerlix roll and replaced the splint that the patient had arrived with. Estimated blood loss was zero. The patient seemed to tolerate the procedure well and left the operating room in good condition. Pathology Report Later Indicated: Non-pressure ulcer with bone necrosis.
I need 1 CPT Code and 3 icd-10-cm codes