DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. History of systemic lupus erythematosus.
2. History of open wounds of scalp.
3. History of lupus vasculitis of scalp.
POSTOPERATIVE DIAGNOSES:
1. History of systemic lupus erythematosus.
2. History of open wounds of scalp.
3. History of lupus vasculitis of scalp.
OPERATION PERFORMED:
1. Debridement of vasculitic ulcers and wounds of scalp including skin, subcutaneous tissue, and muscle.
2. Debridement of bilateral ear ulcers.
SURGEON: John Doe, MD
ANESTHESIA: General.
BLOOD LOSS: Less than 150 mL.
SPECIMENS: Scalp ulcers to the pathologist for assessment for immunofluorescent stain, histopathology, to microbiology for culture and virology studies.
DRAINS: None.
COMPLICATIONS: None.
DESCRIPTION OF OPERATION: After identification of the patient and informed consent, she was taken to the operating room and placed on the table in the supine position. After induction and intubation was obtained with general anesthesia, the scalp was prepped and draped in the usual sterile fashion.
We injected the sites where the lesions were present with 0.25% Marcaine with epinephrine and used a 10 blade scalpel to perform tangential debridement removing only the ulcers and necrotic-appearing subcutaneous tissue, and in a few areas, there were some necrotic-appearing muscle, but for the most part, the galea appeared to be intact, and in none of the wounds were there any periosteum removed. Thus, all wound beds had either galea or at least periosteum present that appeared to be viable. We also debrided the back of the right ear where there was necrotic skin, but the underlying perichondrium appeared to be viable. A small ulcer on the anterior aspect of the left ear was also debrided.
Electrocautery was used to obtained hemostasis. The wounds were irrigated with saline containing bacitracin and covered with bacitracin, Xeroform gauze, and then a head wrap with Kerlix and stockinette. The procedure was well tolerated. The patient was extubated and taken to the recovery room in stable condition.
