Podiatry Medical Transcription Operative Sample Reports For Medical Transcriptionists


DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Right hallux valgus deformity.

POSTOPERATIVE DIAGNOSIS:  Right hallux valgus deformity.

OPERATION PERFORMED:  Right distal first metatarsal osteotomy.

SURGEON:  John Doe, MD

ASSISTANT:  None.

ANESTHESIA:  General with ankle block.

ANESTHESIOLOGIST:  Jane Doe, MD

ESTIMATED BLOOD LOSS:  Minimal.

INDICATIONS:  The patient is a (XX)-year-old female who presents with a torn right anterior cruciate ligament as well as chronic right hallux valgus deformity.  She has undergone a right ACL reconstruction by Dr. Smith today.  Following the completion of her ACL reconstruction, the patient has consented to proceed with correction of right hallux valgus deformity.  Indications for surgery had been discussed with the patient as well as risks and complications including but not limited to infection, bleeding, nerve injury, recurrence of deformity or persistent deformity.  Informed consent was obtained.

DESCRIPTION OF OPERATION:  Following completion of her ACL reconstruction, the right lower extremity was re-prepped and draped.  The right lower extremity was exsanguinated with an Esmarch bandage that was wrapped at the ankle.  A longitudinal incision was made along the medial border of the foot.  The skin was dissected sharply.  Blunt dissection was carried down to the capsule.  A distal and plantar based L-shaped capsulotomy was made using the scalpel.  A small ellipse of capsule was excised.  The dorsal and plantar portions of the metatarsal head were exposed and Homan retractors were placed.  The articular surface was evaluated and noted to be intact.

An oscillating saw was then used to perform a medial eminence resection in line with the medial border of the foot.  More proximal aspect of the metatarsal shaft was then exposed.  A chevron-type osteotomy was then performed using an oscillating saw.  The osteotomy was made so that there was a longer plantar limb.  After completion of the osteotomy, the distal fragment was translated laterally, approximately 4 mm.  Osteotomy was provisionally fixed with a K-wire, and the position was checked under fluoroscopy.  Clinically and intraoperatively, medial sesamoid was noted to be in line with the medial border of the repositioned metatarsal limb.  The metatarsal was fixed with two 2.7 mm screws.  Proximal screw was lagged.

The remaining portion of the medial bone was then trimmed using an oscillating saw.  The wounds were irrigated with normal saline solution.  The hallux was taken through range of motion and noted to be adequate.  The capsule was secured to the bone through a small hole in the cortex made with a K-wire.  The remainder of the capsule was closed using #1 Vicryl suture.  The subcutaneous tissues were closed using inverted #3-0 Vicryl sutures.  The skin was closed using #4-0 nylon.  Xeroform and dry sterile dressings were applied.  The patient tolerated the procedure well.  Prior to dressing the foot, we performed an ankle block using 0.5% Marcaine without epinephrine.  The patient tolerated the procedure well and was transferred to the postanesthesia care unit in stable condition.  There were no intraoperative complications.


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DATE OF OPERATION:  MM/DD/YYYY
 
PREOPERATIVE DIAGNOSIS:  Trimalleolar ankle fracture, left lower extremity.
 
POSTOPERATIVE DIAGNOSIS:  Trimalleolar ankle fracture, left lower extremity.
 
OPERATION PERFORMED:  Open reduction and internal fixation, trimalleolar ankle fracture, left lower extremity.
 
SURGEON:  John Doe, DPM
 
ASSISTANT:  Jane Doe, DPM
 
ANESTHESIA:  General anesthesia.
 
ANESTHESIOLOGIST:  Barbara Doe, CRNA
 
PATHOLOGY:  None.
 
HEMOSTASIS:  Well-padded tourniquet applied to the patient's left lower extremity and inflated to 300 mmHg.
 
ESTIMATED BLOOD LOSS:  Less than 20 mL.
 
MATERIALS:  Four locking screws; one Smith and Nephew locking fibular plate, one 4 mm Smith and Nephew cancellous bone screw, two Synthes cannulated cancellous partially threaded bone screws; 3-0 Vicryl, 4-0 nylon, and skin staples.
 
INJECTABLES:  Approximately 12 mL of 0.5% Marcaine plain was injected to aid in postoperative analgesia.
 
CONDITION:  The patient appeared to tolerate the anesthesia as well as procedure well and was transferred from the operating room to the recovery room with vital signs stable and vascular status intact to the left lower extremity at the conclusion of the procedure.
 
DESCRIPTION OF OPERATION AND FINDINGS:  Under mild IV sedation, the patient was brought to the operating room and placed on the operating room table in supine position. General anesthesia was administered. A well-padded tourniquet was applied to the patient's left thigh. The left lower extremity was scrubbed, prepped and draped in normal sterile fashion. Left lower extremity was exsanguinated. Tourniquet raised to 300 mmHg.

Attention was directed over the lateral aspect of the left lower extremity where a linear incision along the distal aspect of the left lower extremity was performed. Sharp dissection was carried down through sequential layers to the level of bone. The patient was noted to have significant soft tissue disruption as well as evidence of comminution of fibular fracture along its medial aspect. The area was inspected. Fracture line was curetted and irrigated with copious amounts of normal sterile saline. The fracture was reapproximated with the use of alligator bone clamps and held in correct anatomic position.
 
At this time, it was important that observation showed significant osteopenia and osteoporotic bone. Consequently, it was determined to use a 4.0 mm cancellous bone screw as an interfragmentary screw. Therefore, a screw was inserted under standard lag technique. Adequate apposition was obtained. At this time, a 6-hole Smith and Nephew locking plate was used along the lateral aspect of the fibula. Two screws were purchased proximal to the fracture line.

The area was inspected and visualized under sterile-draped C-arm. It was determined adequate anatomic reduction had been achieved and maintained. Consequently, the area was irrigated with copious amounts of normal sterile saline and closed in sequential layers with the use of 3-0 Vicryl for deep and subcutaneous structures. Skin staples were also used.
 
Attention was then directed to medial malleolus where medial malleolus was fixated with the use of two separate percutaneous 4 mm partially threaded cancellous bone screws. The site was visualized under sterile-draped C-arm. Adequate anatomic reduction had been achieved and maintained. Consequently, surgical sites medially were closed with 4-0 nylon. Local anesthesia was subsequently provided. The surgical sites were dressed with Xeroform followed by dry sterile dressings, followed by well-padded posterior splint. The patient was taken from the operating room to the recovery room with vital signs stable and vascular status intact to the left lower extremity.
 


PRESENTING COMPLAINT:  The patient is a (XX)-year-old who presented to my office on XX/XX/XXXX stating that she has tired and achy feet.  The patient stated that she developed left ankle pain after running 2-3 miles, and sometimes, on the weekends, the left ankle pain develops during the run and then is present afterwards and sometimes the next day.  She has also had leg and foot tingling after about 10-15 minutes of treadmill running.  The patient states that her feet and legs just do not feel comfortable at times while at work.  The pain that she feels in her ankle is 5/10.  She denies any morning pain, except some in her ankle.
 
PAST MEDICAL HISTORY:  Unremarkable.
 
PRESENT MEDICAL HISTORY:  Unremarkable.
 
PODIATRIC HISTORY:  Remarkable for a running program every other day, 2-3 miles, and then 7 miles on the weekend.  She denies foot surgery or fractures.  She does not wear orthotics.  Her work shoes are Dansko.  Some of her work shoes are very flexible.  They show a forefoot and lateral wear pattern.
 
PHYSICAL EXAMINATION:
VASCULAR: 
DP: 3/4.
PT: 3/4.
PULSES: Capillary filling time is 2-3 seconds.

VARICOSITIES: Mild.

EDEMA: None.
 
NEUROLOGIC:  There is a positive Tinel's on the right side.  The Tinel sign was also taken in the dorsum of the foot, which was negative.  Vibratory sense was grossly intact.  Deep tendon reflex was 3/5. 
 
DERMATOLOGIC:  Exam was noncontributory.
 
MUSCULOSKELETAL:  Muscle strength was +5/5 and there was no pain in active or passive range of motion.  Off weightbearing, the forefoot was relatively plantarflexed to the heel, and there was a short first metatarsal which was plantarflexed.  The patient is able to raise and invert her heels.  There was mild pain on palpation in the medial aspect of her knees and no other pain could be elicited.  Again, she does have post-static dyskinesia in her left ankle after a lot of activity.  The first ray position is plantarflexed.  The first MPJ range of motion is 65 degrees bilateral, 15 degrees plantar flexion.  There is no genu varum or genu valgum.  The subtalar joint was within normal limits.  Off weightbearing, there is a normal longitudinal arch, and on weightbearing, there is a significant collapse of the arch.  The neutral calcaneal stance is 10 degrees varus.  The resting calcaneal stance is 6 degrees varus and the forefoot position is 10 degrees valgus bilateral.  The ankle dorsiflexion is 10 degrees.  The hip rotation is 15 degrees internal and 50 degrees external.  The hamstring flexibility is 120.  The quadriceps is 130 and the legs were equal length.
 
IMPRESSION:
1.  Forefoot equinus.
2.  Posterior tibial tendinitis of the left.
3.  Possible neuroma symptoms of the third interspace, right foot.
 
TREATMENT PLAN:  The treatment provided for the patient today was discussion of the above and discussed that she needs to wear shoes that have a little bit of a heel raise and that are more supportive.  I discussed her significant forefoot valgus and the side effects that that could have.  We cast her for orthotics today, and she is to return to pick them up.


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Medical Transcription Podiatry Sample Report #4:

PRESENTING COMPLAINT:  The patient is a (XX)-year-old male who presented to my office on XX/XX/XX with two complaints; one, the right big toenail is ugly and the second is right ankle pain of two to three weeks’ duration.  The patient states that he is not as aware of his ankle pain while walking, but more after he stops and sits down, it starts to ache and throb.  He denies any morning pain any more than any other time during the day.  He denies any history of injuries, swelling or ecchymosis.  There have been no prior treatments.

PAST MEDICAL HISTORY:  Remarkable for polio of the left side, but otherwise, he functions quite well.

PRESENT MEDICAL HISTORY:  Unremarkable but for his presenting problem.

PODIATRIC HISTORY:  Significant for his main activity, is golf.  He has a history of foot surgery, which appears to be a fusion of the first MPJ approximately 10 years ago by Dr. Doe.  The patient generally has back pain several times throughout the week.  He wears orthotics, which are over 10 years old and they are of cork and leather style.  His shoe gear is oxford style men’s shoes.

PHYSICAL EXAMINATION:
VASCULAR: 
DP: 2/4 bilateral.
PT: 3/4 bilateral.
PULSES: Capillary filling time is 2-3 seconds.
VARICOSITIES: Mild to moderate.
EDEMA: No edema.

NEUROLOGIC:  Tinel’s was negative.  Vibratory sense was grossly intact.  Deep tendon reflexes 3/5 on the right and 0/5 on the left.

DERMATOLOGIC:  There was a diffuse tyloma on the plantar aspect of the fifth metatarsal of the left foot, and the right hallux nail was distally dystrophic with a clearing at the most proximal aspect.

MUSCULOSKELETAL:  Muscle strength +5/5.  There was no pain on active or passive range of motion.  The right foot, on observation, appeared to have a short first MPJ first ray segment, possibly due to the fusion, and off weightbearing, the foot appeared flat.  The left foot appeared to have a very high longitudinal arch with a plantarflexed first ray.  On stance, the right foot collapsed, and the patient had to bear weight on the forefoot of the left foot, and the left heel maintained a varus position approximately 1 inch off the ground.  This is how the patient ambulates.  The patient was able to raise his heels, but he did have some pain on the right side and the right heel did not significantly invert.  The first MPJ range of motion is 0-5 degrees on the right and approximately 65 degrees on the left.  The first metatarsal is semi-rigid and dorsiflexed on the right and rigid plantarflexed on the left.  There are no contractures of the toes.  There is a possibly mildly enlarged navicular on the right.  The subtalar joint range of motion was limited bilateral.  The neutral calcaneal stance was 6 degrees on the right and was not able to take it on the left due to the heel not contacting the ground.  The resting calcaneal stance was 3 degrees valgus on the right.  The forefoot position of the right foot was 4 degrees varus of the right and 10 degrees valgus of the left.  The leg length difference was that the right leg is approximately 0.5 inch longer than the left.  The ankle dorsiflexion is –3 degrees of the right and –6 degrees of the left, and there was no change with knee flexion.  My exam revealed no pain on palpation of the medial aspect of the tibia or posterior aspect of the medial malleoli.  There was no crepitus noted.  The only area of pain that could be elicited was directly posterior to the medial malleoli of the right foot.

IMPRESSION:
1.  Rule out stress fracture, which I doubt.
2.  Posterior tibial tendinitis.
3.  Leg length difference.
4.  Post-polio effects.

TREATMENT PLAN:
1.  The treatment provided for the patient today was discussion of my findings.  I debrided the right hallux nail and placed him on Penlac.
2.  I told him to start icing his foot and take 10 days’ worth of Vioxx.
3.  I gave the patient a prescription for x-rays that he is to have taken in the next couple of weeks and then give them to me to look at, and I re-casted him for a pair of functional orthosis.  At a later date, we will try to possibly evaluate the patient to ensure a more even gait to help him function and ambulate better.
 
 




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