Incision and Drainage Consent Form
Nitrile exam gloves (1 pair)
Disposable scalpel - 11 blade (1)
Forceps, curved (1 pair)
Forceps, straight (1 pair)
Sterile 4x4 gauze (10)
Iodine swab sticks (3)
Alcohol swabs (10)
1% lidocaine with epinephrine (1 vial)
10 ml syringe (1)
18 gauge 1.5 inch needle (1)
27 gauge 1.5 inch needle (1)
Exam-room sheet (1 sheet)
Chux pads (10)
PILONIDAL CYST INCISION AND DRAINAGE
Risks and benefits of the procedure were discussed, including the risk of bleeding, pain, the need for repeat procedure. Patient indicated understanding and wished to proceed. Timeout performed.
Area cleaned. _ ml of 1% lidocaine with epinephrine injected through the thinnest area of the pilonidal cyst to form a bleb approximately 1 cm off of midline. Using scalpel a linear incision over lidocaine bleb was created, deep enough for pus to exude. Drained _ ml of purulent fluid. Area gently widened with forceps, and gauze applied. Covered with gauze dressing.
Patient tolerated the procedure well with approximately _ ml of bleeding.
Return immediately for fever, significantly worsening pain, spreading redness around the area, or other concerning symptom.