Pyogenic granuloma sinus tract buttock

APPENDIX I r Reports

DIAGNOSES include:

1. Chronic pelvic pain secondary to pelvic metastatic clear cell carcinoma of unknown PrimarY location.

2. Yeta cava sy.rdromi post placement of Hickman catheter' 3. Anemia due to chronic disease. 4. Hypertension.

HOSPITAL COURSE: The patient is a 78-year-old female whom we have

been following in our clinic ior hypertension and also chronic pudendal nerve pain. Shie had been recently biagnosed with pelvic me,tastatic clear

cell caicinoma, which her primaiy location is unknown at this time' She

will be discussing this further after the pathology reports are, read. During her hospital stalia Hickman catheter was placed in order to have IV access for pain medication or future cancer therapy. She was also admitted for

chronic pain. she did develop swelling of her arms and neck. She was

broughtio interventional radiology and she did have venography and the Hickman catheter was removed. Her swelling to her arms and neck have

decreased greatly. She denies any shortness of breath. No choking sensation

as previouily noted. Her pain has been managed well with fentanyl patch at

175 mcg. She has also been on IV heparin therapy for anticoagulation followitig the vena cava syndrome. Today, the patient hasbeen having

complaiits of nausea. She did get some dexamethasone IV for her nausea,

which did improve later this morning. Her blood plessure has been under

good control. Her labs today include a wBC of 5.18, hemoglobin 7.8,

f,ematocrit 23.7, protime 74.4,INR 1'5, PTT 39'6, BUN 6, sodium 139'

potassium 4.2, CO2 27.2.

DISCHARGE, PLANS:

1. IV heparin is discontinued. She will be switched ovel to Lovenox r mg/kg subcutaneously daily. The patient will have Home Health to help her set uP these iniections.

2. She will continue with the fentanyl patch 175 mcg for the pain. 3. She will receive 40,000 units subcutaneously of Procrit at the cancer

center one time per week. we witl follow up in 3 days with a cBC and a basic metabolic Panel.

4. Follow-up uppoittt*ent at the Hypertension Center on November 2 at 10:30 in the morning. Will also iheck-CBC and a basic metabolic panel, PTT, PT, and INR before that appointment'

5. Hotd potassium supplements for now. 6. She *uy rr. fheneigan p.o' 72.5 mg 1-2 tablets p'o' p'r'n' every 6 hours

for nausea. 7. She does have a follow-up appointment set up with Dr. Smith on Friday,

lOlZglXX, to discuss her paihology results and decide what further

treatment is to be done. He will also be discussing plans with Dr. Sticca'

The above plan was discussed with the patient and he.r husband. They

seem to beln agreement. They were encouraged to call our office with any questions or concerns'

DISCHARGE MEDICATIONS:

1. Wili continue home medications. 2. PhenergarrLZ.5 1-2tabs p.o. p.r.n. every 6 hours for nausea' 3. Lovenol 1 mglkg subcutineously every 24 hours. (treattnent for

thromb o sis-bloo d clots)

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APPENDIX A T RCPOTTS

4. Fentanyl patch 175 mcg to be changed every 3 days. (analgesic) 5. Epogen 40,000 units subcutaneously weekly at the Cancer Center.

(treatment for anemia)

Total time spent with the patient today is 60 minutes.

HISTORY: This 1-6-year-old female is seen today after falling off a curb and twisting her right ankle. She is normally a patient of Dr. Anderson, who is out of town this week. (Both physicians are of the same specialty qnd in the same clinic.) She states that she has pain surrounding the entire foot and ankle. Seems unable or unwilling to bear weight. (Problem focused history)

PHYSICAL EXAMINATION: Ankle and foot examined. Foot is warm to touch. Some swelling and bruising noted around the lateral aspect of the ankle. X-ray is negative for fracture. (Problem focused examination)

IMPRESSION: Sprained right ankle. (MDM complexity straightforward)

PLAN: Elevation; ice to affected area. Weight bearing only as tolerated. Return for follow-up P.r.n.

This is a l9-year-old with a living-related donor kidney transplant as of last month and admitted to hospital for possible sepsis.

HISTORY: This patient has tlpe 1 diabetes and had been on dialysis for a number of years before transplantation. She received her mother's kidney on the 14th of last month from the Medical Center Transplant Program in Dallas. She was there this Tuesday for a transplant visit and apparently did not feel well, but they were not certain whether this was a problem or not; but they did go ahead and do blood cultures and called the public health nurse, who was visiting the patient today, and said that one of the cultures was positive for group B strep. The home health nurse called me and stated that the patient has really gone downhill the past few days and was quite fatigued with generalized malaise. Denied cough, fever, or shaking chills but loo[ed poor overall, and the nurse was quite concerned. We recommended she be brought here for evaluation and tleatment as an emefgency' After arrival here, she was in no acute distress. Initially, she had bibasilar crackles on deep breathing; however, most of these cleared. I cannot hear any significlnt pulmonary abnormality on auscultation or percussion. Her heart is normal regular rhythm. No significant murmurs, rubs, 53, or 54. Her abdomen is negative. Her left lower-quadrant kidney is nontender' She has no edema and no lateralizing neural sounds. She is a little lethargic' She does not feel warm. Apparently she is afebrile. Her blood pressure is normal, and she is not tachycardic, but she simply does not look well. Past history, social history, and system review are per our recent o1d chart and noncontributory at Present.

MEDICATIONS: See med sheet.

CLINICAL IMPRESSION: One positive group B strep blood culture, signiflcance, and/or etiology to be determined. My impression at this time is probably a significant finding, and I suspect that this will become a progressive syndrome if not treated.

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APPENDIX A I Reports

This patient continues to be stable with no new problems. Her cultures ,"*ui1negative, and she remains afebrile. Her clearance is pending, but she certainly tias settled down nicely. The main problem w'e a_re having is with her diabetic management. It simply is not working with the former twice a day of 7Ol3O insulin plus a nighttime Lantus. I think we should go one way o.ih. other, and we witt go to Humalog before each meal, starting with an estimated dose of 15 per meal and 40 of Lantus in the evening, and we will titrate from there. We will get Accu-Cheks before each meal to reflect the previous meal's dose of Humalog and adjust it accordingly. Other than that, iornorro* we will review her case with infectious disease with regard to the duration of her antibiotic therapy. Thus far, our cultures have remained negative; however, the positive group B strep is not the type of typical contaminant you get in a blood culture, and we must take it at face value'

Time spent re-evaluating the patient, reviewing the chart, and rearranging

diabetic management was 25 minutes; more than half of the time was coordination.

ADDITIONAL DIAGNOSES:

1. Living-related donor kidney transplant 2. Diabetes mellitus tYPe 1 3. Hypertension

PLAN:Repeatculture.Cultureurine.Dochestx-rayStatandrepeatlab. Wiil empirically treat pending results at this time'

PREOPERATM DIAGNOSIS: Scar right parietal region.

POSTOPERATM DIAGNOSIS: Same.

SURGICAL FINDINGS: 3 x 1 cm elevated scar right parietal region of scalp.

SURGICAL PROCEDURE: Excision scar of scalp'

SURGEON: Dr. Harold Wallingford

ANESTHESIA: General endotracheal anesthesia, plus 2 cc of 10lo Xylocaine and 1 : 100,000 ePinePhrine.

PROCEDURE: The scalp was prepped with Betadine scrub and solution, draped in the routine stedle fashion. The lesion was anesthetized with 2 cc of io/o Xylocaine with 1: 100,000 epinephrine, mostly for the epinephrine effect. After a wait of 4 minutes the lesion was excised, bleeding was electrocoagulated, the wound was closed with vertical mattress sutures of 3-0 Prolene. Surgicel and antibiotic ointment were applied. The patient tolerated the procedure well and left the operating room in good condition.

PATHOLOGY REPORT LATER INDICATED: Benign tissue.

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APPENDIX A I Reports

PRE,0PERATIVEDIAGNOSIS:Lipomaleftposterioraxillaryfold.

POSTOPERATM DIAGNOSIS: Same'

SURGICALFINDINGS:6cmdiameterlipomaattachedtolatissimusdorsi muscle.

PRoCEDURE PERFoRME,D: Excision of lipoma left posterior axillary

fo1d.

ANESTHESIA:Generalendotrachealanesthesiawith5cc|o/oXylocaine with 1:100,000 epinephrine iniected along the incision

line'

COMPLICATIONS: None'

SPONGE AND NEEDLE' COUNT: Correct'

DRAINS: One #10 Jackson Pratt'

DBSCRIPTIONOFPROCEDURE:Thepatient'sposteriorarmwas preppedwithBetadinoscrubandsolutionanadrapedintheroutinesteriie fashion. About s .c oi 1% Xytocaine with 1:100'000 epinephrine

were

injected along ttre inclsion line. Dissection was carrieildown to the site of

theiipomato,s*u,,,*hichwasdissectedfreeoftheskinanddissectedfree of the muscle usingifraip dissection with very little

bleeding' Bleeding was

electrocoagutateA. gecause of the ,ir. oi-it " pocket, we inseited a drain and

brought it out tt ro"gf, u ieparate stab wouni incision using a #10 Jackson

pratt drain. ryr" *o.r'.0 *lJ tn." closed, effectively closing the dead space

with interrupted z-0 Monocryl, subcuticular 3-0 Monocryl, and a few twists

of 4-0 prolene. nr"sti.tg .onriri"A of Kerlix fluffs, Elastoplast' a clavicle

strap, and a sling. il;i;l;;ttolerated the procedure well and left the area

in good condition.

PATHOLOGY REPORT LATER INDICATED: See Report 60'

PREOPERATMDIAGNOSIS:Pyogenicgranuloma'sinustract'buttock'

P'ST.PE.RATTVE DIAGN0SIS: Multiple sinus tracts,- one'extending

inferiorly about 7 x 3 cm in diameter, oni extending to the right

approximately 4 x g .-, *A one 4 x 3 cm extending to the left of 4 x 3 cm'

suRGTcALFTNDTNGS:,Asabove,plus(benign)granulationtissuepresent in a capsule of muttiple ,i.t.$ ftu.ti.'Sinui tracis measured

a total of about

1-5 x 8 im in their total dimensions'

SURGICAL PROCEDURE: Partial unroofrng of sinus tracts' (This is afull-

thickn e s s d eb r i d ement. )

ANESTHESIA: General endotracheal'

DESCRIPTI0NoFPR0CE,DURE:Thepatientwasintubatedandturned in the prone position. A probe was insert6d in the sinus

cavity, and

dissectionwascarriedoowntothis.Iencounteredapieceo-fchronically infectedgranulationtissuecomingoutofahole'inwtrichlstucktheprobe' but this continued for a distan." 10rg", than the probe-and

accordingly, I

put my finger in tt i, u"a irris exteno-ed down the length of my index finger

(i.e., about 7_8 cm Oi iiiit i 'm in width). I left this intact' because this

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APPENDIX A r Reports

would necessitate extensive dissection of 15 sq. cm. of subcutaneous tissue and we have no blood on this patient at this time. We then unroofed two other sinus cavities, and packed this opened with 2-inch vaginal packing and apptied a dlessing and Kerlix plus an Elastoplast. Estimated blood loss: zs cc. The patient seemed to tolerate the procedure well and left the operating room in good condition.-

Coderi euery: It is unclear from the documentation exactly what the procedure was that the physician performed. The coder queried the physician and asked for additional information to ensure correct coding. the physician explained that the patient has a recurrent history of pyogenic granuloma of the buttock with sinus tracts that have, as in this instance, required a subcutaneous tissue debridement.

PREOPERATM DIAGNOSIS: Mass, right breast.

POSTOPERATM DIAGNOSIS: Mass, right breast.

OPERATM PROCEDURE: Right breast mass excision.

PROCEDURE: With the female patient under general anesthesia, the breast and chest were plepped and draped in a sterile manner. An elliptical incision was made in the central portion of the breast about the palpated mass, including the area of the nipple. This was excised all the way down to the fascia of the breast and then submitted for frozen section. Frozen section revealed a carcinoma of the breast with what appeared to be a good margin all the way around it. We then maintained hemostasis with electrocautery and proceeded to close the breast tissue using 2-O and 3-0 chromic. The skin was closed using 4-0 Vicryl in a subcuticular manner. Steri-Strips were applied. The patient tolerated the procedure well and was discharged from the operating room in stable condition.

PATHOLOGY REPORT LATER INDICATED: Primary, malignant neoplasm.

PREOPBRATM DIAGNOSIS: Neck injury, closed posterior cord syndrome caused by a fracture due to a motor vehicle accident'

POSTOPERATM DIAGNOSIS: Same as preoperative.

PROCEDURE PBRFORMED: Placement of halo crown and vest.

ANESTHESIA: Local.

SURGICAL INDICATIONS: This 56-year-old patient was in a motor vehicle accident, hitting a tree. He was the driver and appears to have sustained a cervical spinal cord fracture at C1-4. He could not be placed in a neck collar because he has a short, thick neck and also because he had a tracheostomy tube. The patient would not be stabilized with traction as he has a distraction injury. It was indicated to place him in a halo vest and crown to immobilize his neck.

PROCEDURE: The hair was shaved behind both ears. There was a sterile prep done along the forehead region and the region behind both ears. The halo crown was then positioned and stabilized with the three positioners anteriorly and two laterally. I then iniected Xylocaine behind both ears and

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APPENDIX A r Reports

along the supraorbital ridge laterally. I then placed the Jour pins and torqried tft.- to 8 poundi pel sq inch. The hexagonal lock nuts were then tighlened. The patient tolerated this well without any apparent cdmplications. ihe halo vest was then connected to the crown. The crown was placed. A large vest was used but this was still too small for the patient,

and bn the right ilde the vest had to be tied with string until some permanent straps could be fashioned by orthotics. During the placement of ^the

vest, I maintained the neck in neutral position and at no time was there any rotation or flexion or extension of the neck.

PREOPERATM DIAGNOSIS: Bulky free flap, right heel'

POSTOPERATM DIAGNOSIS: Same.

SURGICAL FINDINGS: 10.5 x 8.5 cm area of redundant fat of flap of right heel.

PROCEDURE PERFORMED: Defatting of flap of right heel with excision of redundant skin (benign).

ANESTHESfA: General endotracheal anesthesia.

POSITION: Prone.

ESTIMATED BLOOD LOSS: Negligible.

DESCRIPTToN oI] PROCEDURE: The patient was intubated and turned into prone position. The right foot and lower leg were prepped with Betadine sciub and solutioi and was draped in the routine sterile fashion' ThemedialaspectoftheflapwaseTevatedexcisingtheoldscarinthe p;;;;;;, ;d the flap was et&ated to about 600/o of its extent to inctude atl oftheredundantfatthatwaswithintheflap'Weremovedabout]..5cm thickness of flap from the bottom of the flap and left a layer of

padding of

about a Cm on the bed' Hemostasis was secured, and then we closed the

woundwithacombinationofplain3-0Proleneandhorizontalmattress sutures and some horizontal hilf mattress sutures of 3-0 Prolene' We dressed the wound,.rrrporuriiy wittr t

proceed

with his Portion of the Procedure'

PREoPERATIVBDIAGNoSIS:Ischialplessureulcerwithmassive ischioperineal and buttock sinus'

POSTOPERATM DIAGNOSIS: Same.

FINDINGS: There was a 2 cm open sutgical ulcer extending down and connecting with an 8 x 30 cm diameter granulation-lined sinus cavity.

SURGICAL PROCEDURE: Excision of left ischial ulcer with total excision of 8 x 30 cm sinus of the buttock, perineal, and ischial areas'

ANESTHESIA: General endotracheal.

ESTIMATED BLOOD LOSS: 400 ml.

FLUIDS: 2liters Ringer's lactate.

DRAINS: None.