DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Wound, left upper arm, measuring 3.5 x 3.5 cm.
POSTOPERATIVE DIAGNOSIS: Wound, left upper arm, measuring 3.5 x 3.5 cm.
OPERATION PERFORMED: Debridement of wound, left upper arm.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: Intravenous sedation and 1% lidocaine with 1:100,000 adrenaline.
COMPLICATIONS: None.
POSTOPERATIVE CONDITION: Good.
DESCRIPTION OF OPERATION: With the patient positioned in the supine position on the operating room table, satisfactory level of intravenous sedation was obtained. The patient’s left arm was placed on an arm broad. The left hand antecubital area was prepped with Betadine gel and draped in a sterile manner.
Attention was then turned to checking the Doppler pulse of the Gore-Tex graft in the arm. It was found to be good. There was necrotic tissue extending down to the level of the Gore-Tex graft, but not exposing the Gore-Tex graft. The muscular fascia seemed to be intact. Fat necrosis was debrided with fine scissors to good bleeding tissue. The wound was profusely irrigated with bacitracin solution. It was felt that at this point in time no grafting or flap transposition could be performed due to the amount of induration of the tissue. Thus, it was decided that the patient would be dressed with antibiotic dressing.
The wound was filled with gentamicin ointment and dressed with Xeroform gauze and occlusive dressing. Home care instructions were given to the patient’s significant other. The patient will be discharged to be treated conservatively as an outpatient for 7 to 10 days and then considered for the possibility of grafting. The above plan was discussed with the significant other and she understands. Dialysis orders were left for dialysis the next day, and the patient was discharged in good condition. The patient will be followed up in the office or will call in the interim for any problems.
