Pre-op Diagnosis: Abscess of right ring finger [L02.511]
Post-op Diagnosis: Same as Pre-op
Procedure(s): Right – INCISION AND DRAINAGE RIGHT RING FINGER – Wound Class: Clean Contaminated – Incision Closure: Deep and Superficial Layers
Proc. Description(s) & CPT Code(s): INCISION AND DRAINAGE RIGHT RING FINGER:
Anesthesia: Monitor Anesthesia Care
Estimated Blood Loss: less than 50 mL
Specimens:
1 : right ring finger Wound Finger, Right 4th
Complications: none
Findings: grossly purulent bulla
Indications:
This is a 72-year-old gentleman who began having severe right ring finger pain that worsened into a purulence below. The patient originally left AMA but returned. The patient has a grossly purulence site on the border of his ring finger from the proximal phalanx down to the fingernail. We discussed the surgical exploration and debridement as needed and the patient chose to proceed.
Technique:
The patient was brought to the operating room and placed in a supine position where he was sterilely prepped and draped. During sterile prepping and draping the bulla burst with a lot of purulence expressed and was cultured.
The patient had a time-out performed and antibiotics were started after cultures obtained.
The bullet was removed including a lot of skin necrosis which was photographed for the epic chart.
Dead skin and subcutaneous tissue was carefully dissected not to remove any of the good healthy tissue remaining. The patient had red beefy granulation tissue after a sharp dissection of the infected tissue over mostly the dorsal and radial border of the finger.
Nonstick, sterile dressings were then applied to the wound and the patient was sent to recovery in stable condition
Disposition: aroused from sedation, and taken to the recovery room in a stable condition
Condition: doing well without problems
CPT code:
26010-F8 : Drainage of finger abscess; simple
ICD 10 code:
L02.511 – Cutaneous abscess of right hand [Active]