Medical Specialty:
Podiatry
Sample Name: Onychomycosis - 1
Description: Onychomycosis present, #1, #2, #3, #4, and #5 right and left.
(Medical Transcription Sample Report)
S: The patient presents to podiatry clinic today at the request of her primary physician, Dr. XYZ for initial examination, evaluation, and treatment of her nails. The patient has last seen primary in December 2006.
PRIMARY MEDICAL HISTORY: Edema, venous insufficiency, schizophrenia, and anemia.
ALLERGIES: THE PATIENT HAS NO KNOWN ALLERGIES.
MEDICATIONS: Refer to chart.
O: The patient presents in wheelchair, verbal and alert. Vascular: She has absent pedal pulses bilaterally. Trophic changes include absent hair growth and mycotic nails. Skin texture is dry. Skin color is rubor. Classic findings include temperature change and edema +1. Nails: Hypertrophic with crumbly subungual debris, #1, #2, #3, #4, and #5 right and #1, #2, #3, #4, and #5 left.
1. Onychomycosis present, #1, #2, #3, #4, and #5 right and left.
2. Peripheral vascular disease as per classic findings.
3. Pain on palpation.
P: Nails #1, #2, #3, #4, and #5 right and #1, #2, #3, #4, and #5 left were debrided for length and thickness. The patient will be seen again at the request of the nursing staff for treatment of painful mycotic nails.
Keywords: podiatry, debrided, thickness, mycotic nails, onychomycosis, nails,
