DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Foreign body, left foot.
POSTOPERATIVE DIAGNOSIS: Foreign body left foot, needle.
OPERATION PERFORMED: Foreign body removal, left foot.
SURGEON: John Doe, MD
ANESTHESIA: Local MAC.
HEMOSTASIS: Ankle tourniquet.
ESTIMATED BLOOD LOSS: None.
MATERIALS USED: #4-0 Prolene.
INJECTABLES: Lidocaine 2% plain.
INDICATION FOR OPERATION: The patient is a (XX)-year-old female who presented to the office today with a complaint of a needle in her left foot for a couple of days in duration. Mom states that she stepped on it while at home. She was seen in the ER at which time they referred to a specialist for further evaluation. We discussed with the mom the need for surgical intervention.
DESCRIPTION OF OPERATION: Under mild IV sedation, the patient was brought to the operating room and placed on the operating table in the supine position. Local anesthetic was utilized over the left foot. The left foot was prepped with Betadine solution. Ankle tourniquet was inflated to 200 mmHg.
Next, attention was directed to the plantar aspect of the left heel, where a small stab incision was performed. Next, under intraoperative fluoroscopy, a straight hemostat was guided until the needle was identified in the heel, at which time the needle was removed under fluoroscopy.
The wound was then irrigated with copious amounts of normal sterile saline. The wound was dressed, 4-0 Prolene retention suture was placed in the left heel. The wound was dressed with Xeroform, 4 x 4s, and Kerlix. The ankle tourniquet was deflated and prompt hyperemic response was noted to all digits of the left lower extremity.
Following a short period of postoperative monitoring, the patient will be discharged home on the following written and oral postoperative instructions:
1. Keep the dressing clean, dry, and intact.
2. Ice and elevate the left foot.
3. Nonweightbearing, left foot.
4. Take medications as directed.
5. Follow up outpatient in the next three to five days for followup postoperative care.
