Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Surgery
Sample Name: Debridement - Foot Ulcer

Description: Debridement of left lateral foot ulcer with excision of infected and infarcted interosseous space muscle tendons and fat. Sharp excision of left distal foot plantar fascia.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSES
1. Left lateral fifth ray amputation site cellulitis with infected left fourth metatarsophalangeal joint.
2. Osteomyelitis of left distal fifth metatarsal bone at left proximal fourth toe phalanx.
3. Plantar fascitis of left distal lateral foot.

POSTOPERATIVE DIAGNOSES
1. Left lateral fifth ray amputation site cellulitis with infected left fourth metatarsophalangeal joint.
2. Osteomyelitis of left distal fifth metatarsal bone at left proximal fourth toe phalanx.
3. Plantar fascitis of left distal lateral foot.

OPERATION PERFORMED
1. Debridement of left lateral foot ulcer with excision of infected and infarcted interosseous space muscle tendons and fat.
2. Sharp excision of left distal foot plantar fascia.

ANESTHESIA: None required.

INDICATIONS: The patient is a 51-year-old diabetic female with severe peripheral vascular disease, who has had angioplasties and single perineal artery runoff to the left leg who developed gangrene of her left fifth toe requiring left fifth ray amputation. She has developed cellulitis of the lateral foot with osteomyelitis and now requires debridement of the local fascitis and necrotic tissue to evaluate for current infectious status and prepare for future amputation.

PROCEDURE IN DETAIL: The procedure was performed in the patient's room. The dressing was removed exposing about a 4 cm x 2.5 cm left distal lateral foot fifth ray amputation open wound. Distally, there is infarcted left fourth metatarsophalangeal joint capsule, as well as plantar fat below the joint.

She has neuropathy allowing debridement of the tissues.

Using sharp scissors and forceps all the necrotic fat and joint capsule area was easily debrided. There was complete infarction of the lateral joint capsule and the head of the phalanx, as well as distal metatarsal head were chronically infected.

The wound was packed with 4x4 gauze pads and dry gauze pads were placed between the toes followed by Kerlix roll pad.

The patient suffered no complications from the procedure.

Keywords: surgery, plantar fascia, foot ulcer, interosseous, metatarsal, cellulitis, amputation, osteomyelitis, plantar fascitis, joint capsule, ray amputation, debridement, plantar, foot,
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