Thigh Wound Incision and Drainage Sample Report
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Infected wound of left posterior thigh with concern for necrotizing soft tissue infection.
POSTOPERATIVE DIAGNOSIS: No necrotizing soft tissue infection.
OPERATION PERFORMED: Incision and drainage of left thigh wound with evacuation of hematoma.
SURGEON: John Doe, MD
ANESTHESIA: Local with IV sedation.
ESTIMATED BLOOD LOSS: None.
OPERATIVE FINDINGS: No evidence of necrotizing soft tissue infection in fascia and old hematoma present.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old gentleman who presented to the ER four days ago for a gunshot wound to the leg. He was seen and released with no evidence of fracture or arterial injury.
He returned to the ER nearly 48 hours ago with bleeding from his wound. He was seen again in the emergency room, and his wound was sutured. He returned today evening with a one-day history of severely increasing pain in his left leg as well as subjective fevers at home.
On examination, the patient was noted to have an approximately 24 x 30 cm area of erythema of his left posterior thigh. This was clearly consistent with a cellulitis. He also had palpable fluid underneath the skin consistent with an abscess. We were also concerned for the possibility of necrotizing soft tissue infection surrounding the wound.
The patient thus presented for incision and drainage of left thigh wound with evacuation of hematoma.
DESCRIPTION OF OPERATION: On the day of the operation, the patient remained in the prone position in the emergency room for incision and drainage of left thigh wound with evacuation of hematoma. His posterior thigh was prepped with Betadine and draped in the standard sterile fashion. After an adequate field block had been achieved with 1% lidocaine, an elliptical incision was made surrounding the old gunshot wound.
This was carried down to the fascia. There was no gross purulence that was encountered. The fascia of the posterior thigh muscles appeared intact and the fat did not separate easily from this. The gunshot wound track was explored with a Yankauer suction, and approximately one unit of blood of old clot was evacuated. There was no active bleeding. There was no evidence of hemorrhage seen. There was no palpable crepitance in the soft tissues.
In short, we concluded that there was no evidence of necrotizing soft tissue infection. Hemostasis was obtained from skin edge bleeding by pressure. The wound was then packed dry and dressed. The patient tolerated the procedure well. The patient will be admitted for IV antibiotics for his cellulitis.
