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Dr. Dennis Yenn's Major Surgeries - H & P
For educational purposes only, residents' use.
PODIATRIC Pre-Op HISTORY & PHYSICAL (sample)
DATE OF SURGERY: 00/00/01
SURGEON: Dr. Dennis Yenn, DPM
ASSISTANT SURGEON (or RESIDENT): Dr. Your name, DPM (PGY2)
PRESENTATION AND HPI: Mr. James Waiter is a 47 year old Persian male who has been complaining of a painful bunion deformity of both his feet, right more than left, progressing for many years, particularly the last 4 years. His condition has hindered his recreational activity level, as well as work schedule as a postal server. This has resulted in difficulty walking as well as complicating situations involving prolonged standing and fitting dressy shoes. He describes his pain as achy in nature, and occasionally throbs especially in the late afternoons. He has tried numerous conservative treatments such as padding, wider shoes and sandals, physical therapy, self massage, bunion night shielding, and over the counter Spenco pre-fab inserts. To his dismay, they have either helped only temporarily or failed and at this time requests for surgical correction of his right bunion deformity.
PAST MEDICAL HISTORY: HTN, arthritis, glaucoma.
CURRENT MEDICATIONS: Indural, Advil, and eye drops (name unknown).
FAMILY HISTORY: father died of heart disease (MI), mother alive w/ NIDDM.
SURGICAL HISTORY: tonsils as a child.
ALLERGIES: Penicillin = rash on the arms and neck.
SOCIAL HISTORY: drinks on social occasions; smokes ½ pac per day for last 4 years.
CURRENT STATUS: The patient states that he has been NPO since 11:00pm. He’s been consented; the form signed and in the chart for the procedure.
PODIATRIC PHYSICAL EXAM:
MUSCULO-SKELETAL: Hallux valgus and bunion deformities right greater than left foot. Large bony prominences with associated palpable bursa, erythema, edema. TTP b/l. R DF MPJ = 20 degrees, PF = 25. L DF = 25 degrees, PF =25. The MPJ’s are trackbound; no crepitus. Muscle strengths are 5/5 for all general muscle groups in the leg and feet. 5th digits both feet are varus rotated.
VASCULAR: +2 DP and +2 PT. Feet room temperature to touch. CFT= 2 sec b/l. No pallor on elevations above the heart. Mild +1 non-pitting edema at bunion deformity locations. Slight talengectasias on medial aspect of R ankle. No varicosities.
DERMATOLOGIC: Hyperkeratosis noted b/l plantar-medial aspects of 1st met head’s and hallux. His 5th digit toenails are dystrophic and mycotic. The rest of the derm exam are within normal limits including nails 1-4 b/l, skin, hair on digits 1-3 b/l, turgour, and mobility.
NEUROLOGICAL: Unremarkablely within normal limits including epicritic (light touch), proprioception, vibratory, sharp-dull, Simm’s 5.07. There are no tinel signs.
RADIOGRAPHIC FINDINGS: X-ray findings are consistent with hallux valgus and bunion deformities both feet, with right greater than left. On the medial aspect of the 1st met heads there are focal cysts as well as localized osteopenia on the AP and MO views. The right 1st MPJ appears mottled degenerative. Both MPJ’s appears congruous and symetrical. The lateral views shows slight elevatus of 1st ray, and mild lose bodies are seen in dorsally. No other incidental findings. Detailed angle measurements are in the office clinic chart.
LABORATORY FINDING: Admission panel and standard blood work on in the chart.
ASSESSMENT:
1) Hallux Valgus and bunion deformity, both feet, R>L.
PLAN:
1) Austin bunionectomy with possible screw fixation, right foot.
________________
By Dr. Your Name, DPM
___________________
For Dr. Dennis Yenn, DPM
Pre-op: Please show up at least 30 minutes prior to the scheduled start time to pre-op the patient. Introduce yourself and please help to make the patient feel at ease, confident, and answer their questions. If they ask, tell them you’re assisting Dr. Yenn. Also, do a pre-op exam of the deformities, so that you are aware of the patient’s history. Focus on the pertinent findings in order to dictate the report.
At the end of your dictation, please conclude with, “this ends the dictation report for patient’s name _______________. My name is Dr. your name dictating for Dr. Yenn. Please mail copies to all physicians listed in the beginning of the dictation including myself. Any questions please page me, Dr. Your Name at 555-555-5555. Thank you for you time.” Write down the report number for future reference.
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Last update: 03/30/05, First update: 03/25/01.
home page: www.dyenn.com