Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Podiatry
Sample Name: Neuroma Excision

Description: Excision of neuroma, third interspace, left foot. Morton's neuroma, third interspace, left foot.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Morton's neuroma, third interspace, left foot.

POSTOPERATIVE DIAGNOSIS: Morton's neuroma, third interspace, left foot.

OPERATION PERFORMED: Excision of neuroma, third interspace, left foot.

ANESTHESIA: General (local was confirmed by surgeon).

HEMOSTASIS: Ankle pneumatic tourniquet 225 mmHg.

TOURNIQUET TIME: 18 minutes. Electrocautery was necessary.

INJECTABLES: 50:50 mixture of 0.5% Marcaine and 1% Xylocaine, both plain. Also, 0.5 mL dexamethasone phosphate (4 mg/mL).

INDICATIONS: Please see dictated H&P for specifics.

PROCEDURE: After proper identification was made, the patient was brought to the operating room and placed on the table in supine position. The patient was then placed under general anesthesia. A local block was then injected into the third ray of the left foot. The left foot was then prepped with chlorhexidine gluconate and then draped in the usual sterile technique. The left foot was then exsanguinated with an Esmarch bandage and elevated and an ankle pneumatic tourniquet was then inflated. Attention was then directed to the third interspace where a longitudinal incision was placed just proximal to the webspace. The incision was deepened via sharp and blunt dissection with care taken to protect all vital structures. Identification of the neuroma was made following plantar flexion of the digits. It was grasped with a hemostat and it was dissected in toto and removed. It was then sent to pathology. The area was then flushed with copious amounts of sterile saline. Closure was with 4-0 Vicryl in the subcutaneous tissue and then running subcuticular 4-0 nylon suture in the skin. Steri-Strips were then placed over that area. A sterile compressive dressing consisting of saline-soaked gauze, ABD, Kling, Coban was placed over the foot. The tourniquet was then released. Good flow was noted to return to all digits. The patient did tolerate the procedure well. He left the operating room with all vital signs stable and neurovascular status intact. The patient went to the recovery. The patient previously had been given both oral and written preoperative as well as postoperative instructions and a prescription for pain. The patient will follow up with me in approximately 4 days for dressing change.

Keywords: podiatry, interspace, ankle pneumatic, pneumatic tourniquet, morton's neuroma, tourniquet, neuroma, foot, anesthesia,
NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports. These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the preference of the dictating physician. All names and dates have been changed (or removed) to keep confidentiality. Any resemblance of any type of name or date or place or anything else to real world is purely incidental.
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Transcribed Medical Transcription Sample Reports and Examples