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Posted By jan on 04-10-2002, 14:44:00 in Emergency Department
The MD states HPI elements qualifying for L4 and para phrasing says pt
has hx of mastectomy sent to ED for possible cellulitis and abscess at
suture site. ROS and PFSH OK for L4
Exam OK L4 also and talks about staples in place, erythema extending
the length of wound, particularly in anterior axillary region with warmth,
induration and purulent drainage from that site.
ED MD states discussed with surgeon, at his instructions, sutures were
removed. The wound was probed and drained as well as irrigated. Large amt
purulent material drained. Packed wiht iodoform gauze.
Final diag: Wound infection status post I&D.
I am not sure there's a procedure here at all. I&D .10060,10061 had
no real incision done, as pt already had one and it opened up with suture
removal(he states but pt did only have staples)Sounds like he probed with
probably forceps and it just drained out.
Not sounding at all to me like puncture aspiration either.10160
What do you all think?? I vote for E&M only.I"m ready for your votes.
Thanks, It's so interesting to hear other's interpretation on what I think
is so clear.