Sample Name: Ingrown Toenail Removal
Description: Painful ingrown toenail, left big toe. Removal of an ingrown part of the left big toenail with excision of the nail matrix.
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Painful ingrown toenail, left big toe.
POSTOPERATIVE DIAGNOSIS: Painful ingrown toenail, left big toe.
OPERATION: Removal of an ingrown part of the left big toenail with excision of the nail matrix.
DESCRIPTION OF PROCEDURE: After obtaining informed consent, the patient was taken to the minor OR room and intravenous sedation with morphine and Versed was performed and the toe was blocked with 1% Xylocaine after having been prepped and draped in the usual fashion. The ingrown part of the toenail was freed from its bed and removed, then a flap of skin had been made in the area of the matrix supplying the particular part of the toenail. The matrix was excised down to the bone and then the skin flap was placed over it. Hemostasis had been achieved with a cautery. A tubular dressing was performed to provide a bulky dressing.
The patient tolerated the procedure well. Estimated blood loss was negligible. The patient was sent back to Same Day Surgery for recovery.
Keywords: podiatry, toenail, nail matrix, ingrown toenail, painful, ingrown,