Sample Name: Plantar Fasciotomy
Description: Plantar fascitis, left foot. Partial plantar fasciotomy.
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Plantar fascitis, left foot.
POSTOPERATIVE DIAGNOSIS: Plantar fascitis, left foot.
PROCEDURE PERFORMED: Partial plantar fasciotomy, left foot.
ANESTHESIA: 10 cc of 0.5% Marcaine plain with TIVA.
HISTORY: This 35-year-old Caucasian female presents to ABCD General Hospital with above chief complaint. The patient states she has extreme pain with plantar fascitis in her left foot and has attempted conservative treatment including orthotics without long-term relief of symptoms and desires surgical treatment. The patient has been NPO since mid night. Consent is signed and in the chart. No known drug allergies.
The incision was then deepened with a combination of sharp and blunt dissection until the plantar fascia was palpated. A #15 blade was then used to transect the medial and central bands of the plantar fascia. Care was taken to preserve the lateral fibroids. The foot was dorsiflexed against resistance as the fibers were released and there was noted to be increased laxity after release of the fibers on the plantar aspect of the foot indicating that plantar fascia has in fact been transacted. The air was then flushed with copious amounts of sterile saline. The skin incision was then closed with #3-0 nylon in simple interrupted fashion. Dressings consisted of #0-1 silk, 4 x 4s, Kling, Kerlix, and Coban. The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted throughout all digits of the left foot. 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 to the left foot. Intraoperatively, an additional 80 cc of 1% lidocaine was injected for additional anesthesia in the case. The patient is to be nonweightbearing on the left lower extremity with crutches. The patient is given postoperative pain prescriptions for Vicodin ES, one q3-4h. p.o. p.r.n. for pain as well as Celebrex 200 mg one p.o. b.i.d. The patient is to follow-up with Dr. X as directed.
Keywords: podiatry, foot, plantar fasciotomy, plantar fascitis, plantar fascia, plantar, fasciotomy, ankle, medially, fascitis, fascia,