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Podiatry Medical Transcription Operative Sample

DATE OF PROCEDURE: XX/XX/XXXX

PREOPERATIVE DIAGNOSIS: Morton neuroma, left second and third metatarsal interspace.

POSTOPERATIVE DIAGNOSIS: Morton neuroma, left second and third metatarsal interspace.

PROCEDURE PERFORMED: Excision of Morton neuroma, left second and third metatarsal interspace.

SURGEON: First Last Name, DPM

ANESTHESIA: Laryngeal mask airway.

PREOPERATIVE ANTIBIOTICS: One gram of Ancef IV.

ESTIMATED BLOOD LOSS: Minimal.

MATERIALS: None.

PROCEDURE IN DETAIL: The patient was brought to the operating room and placed on the operating room table in normal supine position. At this time, a preoperative block was administered with total of 10 mL of 50:50 mixture of 0.5% Marcaine plain and 1% Xylocaine plain about the surgical site, left foot. At this time, a well-padded ankle pneumatic tourniquet was placed just proximal to the malleoli subsequent to Betadine prep. At this time, tourniquet was inflated to 250 mmHg and attention was directed to the left second metatarsal interspace where a 4 cm plantar longitudinal incision was made. Utilizing a 15 blade, the incision was carried deep with careful attention paid to clamp and Bovie all bleeders that were encountered. At this time, the neuroma was brought into the operative field and resected both proximally and distally. The wound was flushed with copious amounts of normal saline and reapproximated utilizing 4-0 Vicryl in simple interrupted fashion. Skin was closed utilizing 4-0 nylon in simple interrupted fashion. The identical procedure was carried out about the third metatarsal interspace plantarly about the left foot. Postoperative injection was administered for a total of 10 mL of 0.5% Marcaine pain. The wounds were dressed with Xeroform gauze, 4 x 4 inch gauze and 3 inch Kling. The patient tolerated the procedure and anesthesia well and left the operating room for the recovery room with vital signs stable and neurovascular status intact, bilateral lower extremities.