Sample Name: I&D & Foreign Body Removal
Description: Incision and drainage and removal of foreign body, right foot. The patient has had previous I&D but continues to have to purulent drainage. The patient's parents agreed to performing a surgical procedure to further clean the wound.
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Foreign body, right foot.
POSTOPERATIVE DIAGNOSIS: Foreign body, right foot.
1. Incision and drainage, right foot.
2. Removal of foreign body, right foot.
HISTORY: This 7-year-old Caucasian male is an inpatient at ABCD General Hospital with a history of falling off his bike and having a root ________ angle inside of his foot. The patient has had previous I&D but continues to have to purulent drainage. The patient's parents agreed to performing a surgical procedure to further clean the wound.
The area was carefully inspected for any remaining piece of foreign body. Several small pieces were noted and they were removed. The area was palpated and there was no more remaining foreign body noted. At this time, the wound was inspected thoroughly. There was noted to be an area along the third metatarsal head more distally that did probe to the bone. There was no purulent drainage expressed. Area was flushed with copious amounts of sterile saline. Pulse lavage was performed with 3 liters of plain sterile saline. Wound cultures were obtained, aerobic and aerobic. The wound was then again inspected for any remaining foreign body or purulent drainage. None was noticed. The wound was packed with sterile new gauze packing lately and dressings consisted of 4x4s, ABDs, Kling, and Kerlix.
The patient tolerated the above procedure and anesthesia well without complications. The patient was transported to the PACU with vital signs stable and vascular status intact. The patient is to be readministered to the pediatrics where daily dressing changes will be performed by podiatry. The patient had a postoperative pain prescription written for Tylenol, Elixir with codeine as needed.
Keywords: orthopedic, incision and drainage, removal of foreign body, purulent drainage, foreign body, metatarsal head, metatarsal, i&d, incision, drainage, foot,