PAST MEDICAL HISTORY: Fairly significant for being diagnosed with D. fragilis and Blastocystis, and he was treated with antibiotics. Since that time, the patient has had a series of laboratory test and consulted a number of rheumatologists to diagnose the cause of joint pains that he had in his elbows and fingers. Six months ago, he consulted a rheumatologist who diagnosed him with Lyme’s disease. He has been placed on Celebrex and Ceftin for the treatment of the Lyme’s disease.

PRESENT MEDICAL HISTORY: Significant for Lyme’s disease. Also seen by Dr. John Doe for hamstring tendonitis. Two years ago, he had a stress fracture of his right tibia.

PODIATRY HISTORY: Remarkable for having a number of orthotics, some semi-rigid and some semi-flexible having a rearfoot post but none appeared to have a forefoot post on them. The shoe gear the patient regularly wears is running shoes for casual wear and school. The wear pattern on the running shoes appeared normal.

PODIATRY PHYSICAL EXAM:
VASCULAR:
DP: 3/4.
PT: 3/4.
PULSES: Capillary filing time is 2-3 seconds.
EDEMA: None and the toes and foot appeared warm.

NEUROLOGIC: Negative Tinel’s, vibratory grossly intact, and deep tendon reflex 3/5.

DERMATOLOGIC: Nonsignificant.

MUSCULOSKELETAL: Muscle strength was +5/5 with no pain on active or passive range of motion. On exam, there was no tenderness that could be elicited on exam of the medial and lateral aspect of the tibia or posterior malleoli. There was pain on palpation of the Achilles tendon approximately 2 inches proximal to the insertion in the watershed area, but there was no crepitus on exam and no fusiform swelling. Visual exam also revealed a dorsal and medial hyperostosis of the first metatarsal head. There was no pain on range of motion of the first MPJ, no crepitus. The dorsiflexion was 20 degrees and plantarflexion 10 degrees. The first ray appeared to be long and semi-rigid. There was a mild HAV. On stance, there was mild midtarsal joint sag along with the collapse of the longitudinal arch. There was no genu valgum or genu varum. The subtalar joint range of motion was normal. The neutral calcaneal stance was 4 degrees varus, resting was 3 degrees valgus, forefoot position was 4 degrees varus bilateral. Ankle dorsiflexion was –2 degrees knee straight and 10 degrees knee bent. Hip rotation was 70 degrees external and 10 degrees internal. Hamstring flexibility was 70 degrees bilateral and quadriceps 130 degrees. Leg length was equal. The knee exam showed no overt swelling or crepitus on range of motion. There was no instability of the knee, and there was pain on palpation of the anterior aspect of the patellar tendon at the site of the attachment of the plantar tendon. There was no pain elicited on exam of the medial aspect of the knee; although, the patient described having medial knee pain distal to the knee joint.

IMPRESSION:
1. A patient with Lyme’s disease but doubt that the patellar tendonitis is directly related to the Lyme’s disease since he has all the biomechanical components for patellar tendonitis.
2. Contracture of the gastroc.
3. Secondary Achilles tendonitis.
4. Contracture of the hamstring complex.
5. Ankle equinus.
6. Hallux limitus.

TREATMENT PLAN: The treatment provided for the patient today was discussion of findings with the patient and his mother, and we started him on aggressive calf stretching and hamstring flexibility program. He is to ice his knee twice a day and he is to wear some heel lift. We dispensed for about a week and then place in his orthotics again and see if they feel more comfortable. He is to return to the office in 2 weeks for podiatry followup at which time we may do a gait analysis and cast him for orthotics.

The post Podiatry Progress Note Medical Transcription Sample Report appeared first on Medical Transcription Phrases, Words, And Helpful Hints.

Podiatry Medical Transcription Operative Sample Reports #1

OPERATION: Endoscopic plantar fasciotomy, right foot.

DESCRIPTION OF OPERATION: Under mild sedation, the patient was brought into the operating room and placed on the operating table in supine position. A pneumatic ankle tourniquet was then placed about the patient’s right ankle. Following IV sedation, a posterior tibial and sural nerve block was performed to the right foot utilizing 10 cc of 1:1 mixture of 1% lidocaine plain and 0.5% Marcaine. The foot was then scrubbed, prepped, and draped in the usual aseptic manner. An Esmarch bandage was then utilized to exsanguinate the patient’s right foot, and the pneumatic ankle tourniquet was then inflated.

Attention was then directed to the medial aspect of the right calcaneus where a 1 cm linear incision was made from superior to inferior, approximately 4 cm anterior to the posterior aspect of the calcaneus and approximately 2 cm superior from the plantar surface of the calcaneus. This incision was then deepened through the subcutaneous tissues, being careful to identify and retract all vital neural and vascular structures. All bleeders were cauterized and ligated as necessary. At this time, a probe was inserted through the medial incision and directed laterally just plantar to the plantar fascia, which could be palpated with the probe. A plane was created between the plantar fascia and the plantar fat pad. The probe was then continued laterally until tenting was noted in the skin over the lateral aspect of the heel.

At this time, the probe was removed and an obturator with a sliding cannula was inserted in its place through the medial incision and directed laterally in the plane between the plantar fascia and the plantar fat pad. Tenting was noted on the lateral aspect of the calcaneus and a #15 blade was then used to make a second 1-cm incision over the tented skin on the lateral surface of the calcaneus. The obturator and sliding cannula were then continued laterally through the lateral incision. The obturator was removed leaving the sliding cannula in place.

An endoscope was then inserted into the cannula through the medial incision and a probe was used to identify the medial band of the plantar fascia through the lateral incision. The probe was removed and a retrograde knife was inserted through the lateral aspect of the cannula and the medial one third of the plantar fascia was incised from medial to lateral, through and through. This required several swipes with the blade. The toes were then dorsiflexed to stretch the cut ends of the fascia away from one another. On doing this, the belly of the flexor digitorum brevis could be visualized through the scope. The endoscope was then removed and reinserted through the lateral opening in the cannula and the medial one third of the plantar fascia was noted to be completely severed. The scope was then removed, and with the cannula in place, the wound was flushed with copious amounts of sterile normal saline. Next, the obturator was reinserted into the cannula, and the obturator and cannula removed as one unit.

Both incisions were then reapproximated and coapted utilizing 5-0 Prolene using interrupted horizontal mattress suture techniques. On completion of the procedure, a total of 1 cc of Decadron phosphate was infiltrated about the incision site. The incisions were dressed with Betadine-soaked Adaptic and covered with sterile compressive dressings consisting of 4 x 4’s and Kling. The pneumatic ankle tourniquet was then deflated and prompt hyperemic response was noted to all digits of the right foot. An Ace wrap was then applied.

The patient tolerated the procedure and anesthesia well. She was transferred to the recovery room with vital signs stable and vascular status intact to all digits of the right foot.

Podiatry Medical Transcription Operative Sample Reports #2

DATE OF OPERATION: MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1. Tarsal coalition with subtalar joint degeneration, left.
2. Equinus deformity, left.

POSTOPERATIVE DIAGNOSES:
1. Tarsal coalition with subtalar joint degeneration, left.
2. Equinus deformity, left.

OPERATION PERFORMED:
1. Subtalar joint arthrodesis, left.
2. Gastroc recession, left.

SURGEON: John Doe, DPM

ASSISTANT: Jane Doe, DPM

ANESTHESIA: General.

HEMOSTASIS: Pneumatic thigh tourniquet 300 mmHg x 92 minutes. The tourniquet was then deflated and reinflated for an additional 92 minutes.

ESTIMATED BLOOD LOSS: Less than 10 mL.

MATERIALS: Grafton bone graft substitute. Free straight iliac crest bone graft and one 7.3 Synthes partially threaded cannulated screw.

INJECTABLES: 20 mL of 0.5% Marcaine plain postoperatively.

PATHOLOGY: None.

COMPLICATIONS: None.

DESCRIPTION OF OPERATION: The patient was consented for the procedure and brought to the operating room, where the name and allergy bands were rechecked. The patient was then brought to the operating room and placed on the table in a modified lateral decubitus position. Attention was then directed to the posterior aspect of the left leg, where a 3 cm incision was made at the gastroc-soleal junction. Care was taken to protect all neurovascular structures. Dissection was carried bluntly down to the gastroc aponeurosis. The aponeurosis was then transected from medial to lateral in toto and good dorsiflexion capability was noted following the procedure. The wound was copiously flushed with normal sterile saline. The subcutaneous tissue was reapproximated with 4-0 Vicryl and skin was reapproximated with 4-0 PDS in intracuticular fashion.

Next, attention was directed to the lateral aspect of the left foot where an incision was made from the distal tip of the fibula, extending up to the base of the fourth metatarsal. A blunt dissection was carried down and all neurovascular structures were identified and protected. The peroneal tendons were freed and retracted distally. Next, the extensor digitorum brevis muscle belly was reflected dorsal and distal and the contents of the sinus tarsi were evacuated. The subtalar joint was unable to be accessed, was opened with a lamina spreader. The cartilage on the calcaneal and talar surface were then denuded and removed with curved osteotome and curettes.

Once we were down to subcondylar bone, subcondylar drilling was performed with a 0.062 K-wire both to the talus and calcaneus and fish scaling was performed with the osteotome. The foot was then placed in an erect position and identified both on lateral and calcaneal axial views. The guide pin for the 7.3 screw was driven from the calcaneus into the talus under fluoroscopic guidance. Care was taken not to invade the ankle joint surface. Next, the 7.3 cannulated screw was inserted in the standard technique. Bone graft substitute was then packed into the subtalar joint. Good stability was noted. There were attempts made to place the second screw. However, due to the nature of the size of the talus, it was impossible. We determined at that point that one screw did provide significant stability across the arthrodesis site.

The wound was copiously flushed with normal sterile saline. The extensor digitorum brevis muscle belly was reapproximated to its anatomical position. Deep structures were reapproximated with 3-0 Vicryl, subcutaneous with 4-0 Vicryl, and the skin reapproximated with skin staples. The screw holes were then reapproximated with 3-0 nylon in a simple interrupted fashion. Wounds were then dressed with Xeroform. Dry sterile, 4 x 4s multilayered Jones compression bandage was applied postoperatively. The patient tolerated the procedure and anesthesia well and left the OR and to the recovery room with vital signs stable and vascular status intact. No complications were noted. The patient will be admitted for postoperative convalescence and pain management.

Podiatry Medical Transcription Operative Sample Reports #3

OPERATIONS:
1. Clayton procedure, left foot, panmetatarsal head resection of 2 through 5.
2. Left correction of bunion.
3. Left second digit arthroplasty.

PROCEDURE IN DETAIL: Under mild sedation, the patient was brought to the operating room and placed on the operating table in a supine position. A well-padded pneumatic ankle tourniquet was placed about the patient’s left ankle. MAC anesthesia was given as well as a local block consisting of 20 cc of 1:1 mixture of 0.5% Marcaine plain and 1% lidocaine plain. Foot was then scrubbed, prepped, and draped in the usual aseptic manner. The limb was then elevated. Ankle tourniquet was then inflated. Attention was then directed to the second and fourth interspace, where approximately 3-cm linear longitudinal incision was made encompassing a past scar. The incision was deepened using sharp and blunt dissection. Care was taken to retract all vital neurovascular structures. The second metatarsal head was then identified through the second interspace incision. This was freed of all attachments using sharp and blunt dissection as well as the McGlamry elevator. The second, third, fourth, and fifth metatarsal heads were all freed in the same fashion. Next, utilizing the oscillating bone saw, the heads of the metatarsals were transected (the second, third, fourth, and fifth) and passed from the operative site in toto.
Next, attention was then directed to the first metatarsal where a linear longitudinal incision was made medial and parallel to the extensor tendon along the first metatarsal. Incision was deepened using sharp and blunt dissection. Care was taken to retract all vital neurovascular structures. The head of the metatarsal was freed and identified, and using a crescentic blade, the head of the metatarsal was transected. The sesamoids were left in position. All cartilaginous surfaces and medial bump prominence were resected and passed from the operative site.

Next, attention was then directed to the second digit, which was contracted and elongated and a 2-cm linear longitudinal incision was made over the extensor tendon. The extensor tendon was transected. The collateral ligaments were released. The head of the proximal phalanx was exposed. It was transected utilizing an oscillating bone saw and passed from the operative site in toto. The foot was reassessed now and found to be in a more corrected position with less plantar pressure in a retrograde fashion. A 0.045 K-wire was passed through the second digit into the remaining metatarsal stump as well as in the fourth digit into the remaining metatarsal stump and into the first digit into the metatarsal. All wounds were then irrigated with copious amounts of normal sterile saline. The foot was then checked under C-arm and adequate alignment was noted at this time. A TLS drain was placed.

All wounds were closed in a layered fashion and dressed with Steri-Strips, Betadine-soaked Adaptic, as well as sterile compressive dressing consisting of 4 x 4’s and Kling. A posterior splint was applied. The pneumatic ankle tourniquet was released. Prompt hyperemic response was noted to all digits of the left foot following a period of postoperative monitoring. The patient tolerated the procedure well. The patient was transferred from the OR to the recovery room. Vital signs were stable, and neurovascular status was intact to all digits of the left foot.

Podiatry Medical Transcription Operative Sample Reports #4

OPERATIONS:
1. Left third distal interphalangeal joint arthroplasty with K-wire fixation.
2. Flexor digitorum longus tenotomy, left third digit.
3. Right hallux interphalangeal joint condylectomy.

DESCRIPTION OF PROCEDURE: Under mild sedation, the patient was brought to the operating room and placed on the operating room table, where left and right well-padded pneumatic ankle tourniquets were placed. Next, the above-mentioned cocktail was injected on the left third digit, in a digital block and a hallux block about the right foot. Both feet were prepped and draped in the usual aseptic manner. The left foot was then elevated in an approximately 45-degree angle and exsanguinated using an Esmarch bandage.

Next, a semi-elliptical incision was made dorsally about the third distal interphalangeal joint. The skin was reflected and removed. The sharp and blunt dissection continued down to the subcutaneous tissue, retracting all neurovascular structures and ligating all necessary bleeders. Dissection was carried down to the extensor digitorum longus tendon, which was identified and reflected both proximally and distally.

Next, all soft tissue attachments were reflected off of the intermediate phalanx head. An oscillating saw was then utilized to resect the intermediate phalanx head. Dissection was carried down plantarly to identify the flexor digitorum longus tendon, which was then tenotomized. The wound was flushed and irrigated using copious amounts of normal sterile saline.

Next, a 0.045 K-wire was inserted through the base of the distal phalanx and was inserted in the intermediate phalanx and to the proximal phalanx in a retrograde fashion. Fluoroscopy was utilized to confirm proper K-wire placement, which was noted to be adequate. Deep closure was obtained using Vicryl suture. Skin was closed and reapproximated using Novafil suture. The wound was dressed with Steri-Strips, Betadine-soaked Adaptic, 4 x 4 gauze, Kling, and an Ace bandage. The left tourniquet was then deflated.

Next, the right foot was elevated at an approximately 45-degree angle and exsanguinated using an Esmarch bandage. Attention was then directed to the medial aspect of the hallux interphalangeal joint, where an approximately 2.5 cm incision was made. Sharp and blunt dissection was carried down to the subcutaneous tissue retracting all neurovascular structures and ligating all necessary bleeders. Careful dissection continued until the condyles of the base of the distal phalanx medially and condyle of the proximal phalanx distally was exposed. Dissection was utilized to free up all soft tissue attachments by paying careful attention to preserve the flexor and extensor tendons.

Next, an oscillating saw was utilized to resect the condyles at the interphalangeal joint. A rongeur was utilized to remove any other excessive hypertrophic bone. It was noted that no hypertrophic bony prominences remained. The wound was flushed and irrigated using copious amounts of normal sterile saline. Fluoroscopy was then utilized to confirm proper resection of bone. It was noted that adequate resection was achieved. Deep closure was obtained using Vicryl suture, and skin was closed and reapproximated using Novafil suture.

The wound was dressed with Steri-Strips, Betadine-soaked Adaptic, 4 x 4 gauze, Kling, and Ace bandage. The tourniquet was deflated. The patient tolerated the anesthesia and procedure well, returned to the PACU with vital signs stable and hyperemia to all digits.

The post Podiatry Medical Transcription Operative Sample Reports For MTs appeared first on Medical Transcription Phrases, Words, And Helpful Hints.

abduction brace

abduction hip splint

abduction pillow

active-assisted range-of-motion exercise

activities of daily living

adaptive devices

American Spinal Injury Association (ASIA) scale

ankle-foot orthosis or AFO

ankle-pump exercise

antidecubitus mattress

aquatic therapy

arm trough

aspiration precautions

assistive devices

balance board

bathroom equipment

bed mobility

bed rails

bedside commode

bed-to-wheelchair transfers

broad-based cane

broad-based gait

buddy strap/splint

Bunny boot

calcaneal stance

chin tuck technique (dysphagia patients)

compensatory techniques

contact guard assistance

CPM (continuous passive motion) device

dependent for all self-care activities

dressing stick

eggcrate mattress

electrical stimulation

elevating leg rest

energy conservation techniques and pacing

footdrop gait

front-wheel walker

functional transfers

gentle passive range of motion

give-way weakness

Glasgow coma scale score

grip strength

halo vest

hand grasp strength

handicap parking placard

HBO therapy

heel lift

hospital bed

Hoyer lift

hygiene, feeding, grooming, upper and lower body dressing,

and transfer skills

joint laxity

Kydex jacket

lightweight wheelchair

LiteGait device

long handle shoe horn

long handle sponge

lumbosacral corset

maximal assistance, moderate assistance, minimal assistance

maximal assistance for grooming

Minerva vest

minimal/maximal assistance

modified independence level

moist heat therapy

Moon boot

motorized scooter

motorized wheelchair

one-person assistance, two-person assistance

oral motor control

parallel bars

passive resistive exercise

physical therapy, occupational therapy, rehab nursing, therapeutic

recreation

pregait and gait training

pressure relief ankle foot orthosis or PRAFO

psychomotor performance

quad cane

quad knobs and brake extenders

raised toilet seat

Rancho ankle foot control device

range of motion

recreational therapy

requires setup for

rickshaw rehabilitation exerciser

ROHO bed

rolling walker

safety awareness

self-care independence

self-care skills

self-propel wheelchairs

shoe lift

shower chair

single-point cane

sit to stand

sitting/standing balance

sliding board transfers

sock aid and reacher

spinal cord injury orientation session

spinal precautions

standard leg rest

standby to contact guard assistance

supervised level with

swing-through gait

swing-through phase of ambulation

team conference

TED hose

Thera-Band

therapeutic recreation

toe-touch weightbearing status

toilet-to-tub/shower transfers

total dependence

trapeze

Trendelenburg gait

Vail bed

Venodyne boot

vibratory stimulation

weightbearing as tolerated

whirlpool therapy

PODIATRY TERMS:

ankle dorsiflexion

balls of feet

Birkenstock orthotic/shoe

bunion

calcaneal cuboid joint

collapse of the arch

cryptotic nails

curve-lasted shoe

debride nails

dystrophic nails

exostosis

first MJP

functional hallux limitus

gel heel lifts

Haglund deformity

hallux

HAV deformity

heel pads

heel protectors

hyperostosis

ingrown nails

IPJ ossicle

longitudinal arch

metatarsus adductus deformity

midtarsal joint sag

navicula

neutral calcaneal stance

onychauxis

onychocryptosis

onychomycosis

orthotics

plantar fasciitis

plantarflexed

poststatic dyskinesia

proprioceptive exercises

raise and invert heels

sinus tarsi area

Spenco inserts

Superfeet orthotic insole

too-many-toe sign

tyloma

underlapping toe

varus rearfoot wedge

visual gait analysis

walking cast boot

The post Physical Medicine and Rehab / Podiatry Terms For MTs appeared first on Medical Transcription Phrases, Words, And Helpful Hints.