Sample Name: Onychomycosis - 2
Description: Onychomycosis present, #1 right and #1 left.
(Medical Transcription Sample Report)
S: The patient presents to Podiatry Clinic today for initial examination, evaluation, and treatment of her nails.
PRIMARY MEDICAL HISTORY: Adenocarcinoma, delirium, recent dehydration, anemia, history of hypertension, and hyperlipidemia.
MEDICATIONS: Refer to chart.
ALLERGIES: PENICILLIN AND ASPIRIN.
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 and shiny. Skin color is rubor. Classic findings are temperature change and edema +1. Nails: Hypertrophic with crumbly subungual debris, # 1 right and #1 left.
1. Onychomycosis present, #1 right and #1 left.
2. Peripheral vascular disease as per classic findings.
3. Pain on palpation.
P: Nails #1 right and #1 left were debrided for length and thickness. All the nails were reduced. The patient will be seen at the request of the nursing staff for treatment of painful mycotic nails.
Keywords: podiatry, length and thickness, mycotic nails, classic findings, onychomycosis, nails,