DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Hyperkeratotic nails, left, digits one through five and right thumb and index fingers.
POSTOPERATIVE DIAGNOSIS: Hyperkeratotic nails, left, digits one through five and right thumb and index fingers.
PROCEDURE PERFORMED: Removal of nails, left, digits one through five and right thumb and index finger.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: MAC.
COMPLICATIONS: None.
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old male with a history of psoriasis as well as hemiplegia, who has little functional use of his right upper extremity. Over the last couple of months, the patient has had hyperkeratotic growth of his nails in all digits of his left hand as well as his right thumb and index finger. His nails are impairing the functional use of his left hand. The patient was brought to the operating room for excision of these hyperkeratotic nails.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and laid supine on the OR table. After MAC anesthesia was induced, all the nails on his left hand, digits one through five, were removed without difficulty. We were able to just peel off the nails at their base. Next, a knife was used to clean off any residual keratotic material off the nail beds. Next, all nails were thoroughly irrigated with normal saline and covered with Adaptic and sterile dressings.
Attention was then directed towards the right hand. The right hand was also prepped and draped, and the nails on the thumb and index finger were again removed without much difficulty. Again, the keratotic material was cleaned off the nail bed with a knife. Bacitracin, Adaptic, as well as sterile dressings were also applied after thorough irrigation of these nail beds.
The patient was then awakened and transferred back onto the stretcher and taken to the PACU for recovery. There were no complications.
