DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Multiple scalp abscesses.
POSTOPERATIVE DIAGNOSIS: Multiple scalp abscesses.
PROCEDURE PERFORMED: Incision and drainage of multiple scalp abscesses.
SURGEON: John Doe, MD
ANESTHESIA: MAC.
ESTIMATED BLOOD LOSS: 15 mL.
INDICATIONS FOR PROCEDURE: This is a (XX)-year-old male with about a two-week history of what was thought to initially be a fungal infection of his scalp but became progressively purulent. He was admitted with leukocytosis and multiple abscesses of the scalp. He has also multiple areas that are denuded of hair. There are multiple tender fluctuant areas as well as multiple small pustules.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and sedation was provided. Local anesthetic used was 0.5% Marcaine with epinephrine. A total of 10 mL was used. Blunt pressure was used to penetrate these follicular pores, which had a white purulent discharge, and this was done with small hemostats and probed.
First, the largest one at the upper portion of his scalp, anterior midline, had approximately 3 cm area of fluctuance and denuded of hair. This area had multiple white draining sinuses. One of these sinuses was probed, and the area widened bluntly with a hemostat, and there was no extension noted to the deeper scalp tissue or galea.
The clamp was then probed laterally subcutaneously, and it was noted that these pustular pockets were primarily in the dermal layer. Small sample was excised using Metzenbaum scissors and sent to pathology.
Once this larger area was probed and drained, then multiple small areas were probed and also drained in a similar fashion; that is by first probing the draining sinus and then widening the opening, allowing the deeper purulent material to drain. The material in all these areas was similar, that is white in nature. Prior to this, the scalp was prepped with Betadine and also the scalp was washed with ChloraPrep scrub. The scalp thus was progressively inspected, and all major palpable small abscesses were drained using this method.
The scalp was then cleansed once again with saline, dried, and then a dry sterile dressing was applied. The patient tolerated the procedure well without complications. He was then transferred to the recovery room in stable condition.
