Patient Name: Gerald Edwards
Hospital No.: 11058
Date of Surgery: 07/17/2010
Admitting Physician: Catherine Baker, MD
Surgeon: Gary Sheldon, DPM
Preoperative Diagnosis: Diabetic plantar space abscess of the right foot, and grade 2 diabetic ulceration of the right foot. Postoperative Diagnosis: Diabetic plantar space abscess of the right foot, and grade 2 diabetic ulceration of the right foot. Operative Procedure: Complicated incision and drainage of the right foot anesthesia spinal with IV sedation. FINDINGS: Please refer to the extensive preoperative history and physical report and consultation. SUGURICAL FINDINGS: There is a one centimeter diameter ulcer sinus tract in the central part of the right fore foot. There is an ulceration of a proximately of 6 cms in diameter beneath the medial cuneiform. The forefoot is indurated and arrhythmias, there is calor. PROCEDURE: The patient was brought into the operating room and placed on the operating table where spinal anesthesia was induced. The right lower extremity was prepped with bednine solution. A newmatic ankle tourniquet was placed over Webril padding above the right ankle joint. The leg was evaluated for proximately two minutes and the tourniquet was raised to 275 millimeters of mercury. An S-shaped curved incision through the right plantar fore foot ulceration was made down to abyss cavity where a moderate amount of sanguinopurulent discharge was noted. There was minimal odor noted to the region. There was mild venus bleeding noted on the edges of the incision. The cavity was probed and found to go deep into the musculatory layer plain between the bone and fascia. The proximal ulceration abscess cavity was linked to the lateral aspect of the sub cuneiform ulceration. There were a few areas of necrotic tissue noted. These appeared to be tenderness and fibrotic in structure. The ulceration tract proximately to the ulcer but did not extend proximately pass the ulcer....
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