Sample Type / Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Infected Toenails
This patient has reoccurring ingrown infected toenails.
(Medical Transcription Sample Report)
This patient has reoccurring ingrown infected toenails. He presents today for continued care.O -
On examination, the left great toenail is ingrown on the medial and lateral toenail border. The right great toenail is ingrown on the lateral nail border only. There is mild redness and granulation tissue growing on the borders of the toes. One on the medial and one on the lateral aspect of the left great toe and one on the lateral aspect of the right great toe. These lesions measure 0.5 cm in diameter each. I really do not understand why this young man continues to develop ingrown nails and infections.A -
2. Benign lesions.P -
Aseptic technique was used and the medial and the lateral toenail border was excised from the left great toe. The medial aspect of the left great toenail was excised, the lateral aspect of the left great toenail was excised, also the benign lesion on the medial aspect of the left great toe and the benign lesion growing on the lateral aspect of the left great toe were excised. Blood loss was less than 5 cc. Hemostasis was achieved and the left great toe was dressed with Neosporin ointment and absorbent dressing. The lateral aspect of the right great toenail was also excised and the benign, which measured 0.5 cm in diameter as all 3 benign lesions did measure was excised. Blood loss was less than 5 cc. Hemostasis was achieved and the left great toe and the right great toe were both dressed with Neosporin ointment and absorbent dressing. Rx Keflex 500 mg #30 sig 1 TID with food, 1 refill. Followup with this clinic in 8 days.
soap / chart / progress notes, infected toenails, onychocryptosis, benign lesions, toenail border, left great toe, neosporin ointment, hemostasis was achieved, ointment and absorbent, toenails, ingrown, lesions, benign, infected,
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.