How to evaluate and do medical recordings on postoperative skin wounds

Physicians and surgeons evaluate the wounds or incisions after an operation or surgery.

Question: how should they evaluate and do medical recordings on these postoperative skin wound or incision?

Here are my thoughts, perceptions, opinions and recommendations and these are what I usually do in my practice.

If I have these findings and I note them down in my charts:

  • Wound dry
  • Wound edges well co-aptated
  • No redness or erythema
  • No discoloration – no purplish or blacklist discoloration to suggest necrosis
  • No unusual bulge to suggest fluid collection underneath the wound

I will make an evaluation of “wound healing well.”

Illustration:

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Wound healing well – one week after minilap open cholecystectomy – note the scab formation on the inner side of the wound. This is not necrosis.

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Wound well healed – one week after appendectomy.

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Wound well healed – one week after total mastectomy and axillary dissection.

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Wound well healed one week after bilateral total mastectomy and axillary dissection.

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Wound well healed – one week after thyroidectomy.

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Wound well healed several months after thyroidectomy.

If there is redness or erythema, the possibilities are and their accompanying findings:

  • Inflammation – such as caused by stitch reaction
  • Infection – tenderness, fluctuant mass indicating an abscess, purulent discharge

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Redness caused by inflammation from stitch reaction.

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After drainage of infection.

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Stitch inflammation with dehiscence (gaping wound).

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After drainage of infection

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Infection – as evidenced by redness and pus.

If there is discoloration of wound edges, the possible scenarios are suspicion for necrosis; beginning necrosis; and established necrosis.   The necrosis has to be differentiated from scabs formation.

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Suspicion for flap necrosis or start of necrosis

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Established flap necrosis.

If there is unusual bulge suggestive of fluid collection, the latter can be a seroma, hematoma or pus.

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Bulge on the side.

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Showing hematoma causing the bulge (on needle aspiration).

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Bulge on the side of the wound and after aspirating, yielding seroma (yelllowish fluid to distinguish it from blood of hematoma and pus from infection or abscess).

ROJ-TPOR@17jan23

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