Medical Specialty: Orthopedic
Sample Name: Lumbar Spine HNP - Consult

CHIEF COMPLAINT:, Low back pain and right lower extremity pain. The encounter reason for today's consultation is for a second opinion regarding evaluation and treatment of the aforementioned symptoms.,HPI - LUMBAR SPINE:, The patient is a male and 39 years old. The current problem began on or about 3 months ago. The symptoms were sudden in onset. According to the patient, the current problem is a result of a fall. The date of injury was 3 months ago. There is no significant history of previous spine problems. Medical attention has been obtained through the referral source. Medical testing for the current problem includes the following: no recent tests. Treatment for the current problem includes the following: activity modification, bracing, medications and work modification. The following types of medications are currently being used for the present spine problem: narcotics, non-steroidal anti-inflammatories and muscle relaxants. The following types of medications have been used in the past: steroids. In general, the current spine problem is much worse since its onset.,PAST SPINE HISTORY:, Unremarkable.,PRESENT LUMBAR SYMPTOMS:, Pain location: lower lumbar. The patient describes the pain as sharp. The pain ranges from none to severe. The pain is severe frequently. It is present intermittently and most of the time daily. The pain is made worse by flexion, lifting, twisting, activity, riding in a car and sitting. The pain is made better by laying in the supine position, medications, bracing and rest. Sleep alteration because of pain: wakes up after getting to sleep frequently and difficulty getting to sleep frequently. Pain distribution: the lower extremity pain is greater than the low back pain. The patient's low back pain appears to be discogenic in origin. The pain is much worse since its onset.,PRESENT RIGHT LEG SYMPTOMS:, Pain location: S1 dermatome (see the Pain Diagram). The patient describes the pain as sharp. The severity of the pain ranges from none to severe. The pain is severe frequently. It is present intermittently and most of the time daily. The pain is made worse by the same things that make the low back pain worse. The pain is made better by the same things that make the low back pain better. Sleep alteration because of pain: wakes up after getting to sleep frequently and difficulty getting to sleep frequently. The patient's symptoms appear to be radicular in origin. The pain is much worse since its onset.,PRESENT LEFT LEG SYMPTOMS:, None.,NEUROLOGIC SIGNS/SYMPTOMS:, The patient denies any neurologic signs/symptoms. Bowel and bladder function are reported as normal.
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DESCRIPTION: Low back pain and right lower extremity pain - Lumbar spine herniated nucleus pulposus.

The situation involves a medical consultation regarding severe and chronic pain affecting the patient's daily life due to a lumbar spine herniated nucleus pulposus (HNP). Although this is a significant health concern, it is not immediately life-threatening. The stakes are higher because it could affect the patient's quality of life and ability to perform daily activities if not addressed. However, there are no complications such as neurological deficits or disturbances in bowel/bladder function, which would increase the stakes further. Thus, while important to address, this situation is not extremely high-stakes in a life-threatening sense.


You are an LLM as part of a medical assistant system, interacting with medical practitioners to improve efficiency.

Medical Specialty: Orthopedic
Sample Name: Lumbar Puncture - 2

PROCEDURE PERFORMED:,  Lumbar puncture.,The procedure, benefits, risks including possible risks of infection were explained to the patient and his father, who is signing the consent form.  Alternatives were explained.  They agreed to proceed with the lumbar puncture.  Permit was signed and is on the chart.  The indication was to rule out toxoplasmosis or any other CNS infection. ,DESCRIPTION: , The area was prepped and draped in a sterile fashion.  Lidocaine 1% of 5 mL was applied to the L3-L4 spinal space after the area had been prepped with Betadine three times.  A 20-gauge spinal needle was then inserted into the L3-L4 space.  Attempt was successful on the first try and several mLs of clear, colorless CSF were obtained.  The spinal needle was then withdrawn and the area cleaned and dried and a Band-Aid applied to the clean, dry area.,COMPLICATIONS:,  None.  The patient was resting comfortably and tolerated the procedure well.,ESTIMATED BLOOD LOSS: , None.,DISPOSITION: , The patient was resting comfortably with nonlabored breathing and the incision was clean, dry, and intact.  Labs and cultures were sent for the usual in addition to some extra tests that had been ordered.,The opening pressure was 292, the closing pressure was 190.
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DESCRIPTION: Lumbar puncture.  A 20-gauge spinal needle was then inserted into the L3-L4 space.  Attempt was successful on the first try and several mLs of clear, colorless CSF were obtained.

orthopedic, spinal needle, lumbar puncture, lumbar, gauge, csf

This situation involves a lumbar puncture procedure, which is an invasive medical procedure conducted to obtain cerebrospinal fluid (CSF) for diagnostic purposes. While the procedure itself is commonly performed and complications are rare, it still carries risks such as infection, bleeding, or damage to nearby structures. The procedure was performed successfully with no complications reported, indicating a low likelihood of immediate adverse outcomes. However, due to the nature of the procedure and the potential implications of the findings (ruling out serious conditions like CNS infections), it carries moderate considerations in terms of stakes.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Orthopedic
Sample Name: Lumbar Discogram

PREOPERATIVE DIAGNOSIS: , Low back pain.,POSTOPERATIVE DIAGNOSIS: , Low back pain.,PROCEDURE PERFORMED:,1.  Lumbar discogram L2-3.,2.  Lumbar discogram L3-4.,3.  Lumbar discogram L4-5.,4.  Lumbar discogram L5-S1.,ANESTHESIA:  ,IV sedation.,PROCEDURE IN DETAIL:  ,The patient was brought to the Radiology Suite and placed prone onto a radiolucent table.  The C-arm was brought into the operative field and AP, left right oblique and lateral fluoroscopic images of the L1-2 through L5-S1 levels were obtained.  We then proceeded to prepare the low back with a Betadine solution and draped sterile.  Using an oblique approach to the spine, the L5-S1 level was addressed using an oblique projection angled C-arm in order to allow for perpendicular penetration of the disc space.  A metallic marker was then placed laterally and a needle entrance point was determined.  A skin wheal was raised with 1% Xylocaine and an #18-gauge needle was advanced up to the level of the disc space using AP, oblique and lateral fluoroscopic projections.  A second needle, #22-gauge 6-inch needle was then introduced into the disc space and with AP and lateral fluoroscopic projections, was placed into the center of the nucleus.  We then proceeded to perform a similar placement of needles at the L4-5, L3-4 and L2-3 levels.,A solution of Isovue 300 with 1 gm of Ancef was then drawn into a 10 cc syringe and without informing the patient of our injecting, we then proceeded to inject the disc spaces sequentially.
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DESCRIPTION: Lumbar discogram L2-3, L3-4, L4-5, and L5-S1.  Low back pain.

orthopedic, back pain, c-arm, fluoroscopic projections, disc space, lumbar discogram, fluoroscopic, needle,

This situation involves a lumbar discogram procedure, which is a diagnostic tool used to determine the source of back pain. While any medical procedure carries some level of risk, a lumbar discogram is generally considered to be a routine procedure that is minimally invasive. The stakes would be higher if the procedure were therapeutic rather than diagnostic or if there were significant risks or complications involved. However, the risk involved here is typical of diagnostic procedures and does not reach high-stakes territory compared to other orthopedic or medical procedures.


Medical Specialty: Orthopedic
Sample Name: Laminectomy & Foraminotomy & Cervical Fusion

PREOPERATIVE DIAGNOSES,1.  Post anterior cervical discectomy and fusion at C4-C5 and C5-C6 with possible pseudoarthrosis at C4-C5.,2.  Cervical radiculopathy involving the left arm.,3.  Disc degeneration at C3-C4 and C6-C7.,POSTOPERATIVE DIAGNOSES,1.  Post anterior cervical discectomy and fusion at C4-C5 and C5-C6 with possible pseudoarthrosis at C4-C5.,2.  Cervical radiculopathy involving the left arm.,3.  Disc degeneration at C3-C4 and C6-C7.,OPERATIVE PROCEDURES,1.  Decompressive left lumbar laminectomy C4-C5 and C5-C6 with neural foraminotomy.,2.  Posterior cervical fusion C4-C5.,3.  Songer wire.,4.  Right iliac bone graft.,TECHNIQUE:  ,The patient was brought to the operating room.  Preoperative evaluations included previous cervical spine surgery.  The patient initially had some relief; however, his left arm pain did recur and gradually got worse.  Repeat studies including myelogram and postspinal CTs revealed some blunting of the nerve root at C4-C5 and C5-C6.  There was also noted to be some annular bulges at C3-C4, and C6-C7.  The CT scan in March revealed that the fusion was not fully solid.  X-rays were done in November including flexion and extension views, it appeared that the fusion was solid.,The patient had been on pain medication.  The patient had undergone several nonoperative treatments.  He was given the option of surgical intervention.  We discussed Botox, I discussed with the patient and posterior cervical decompression.  I explained to the patient this will leave a larger scar on his neck, and that no guarantee would help, there would be more bleeding and more pain from the posterior surgery than it was from the anterior surgery.  If at the time of surgery there was some motion of the C4-C5 level, I would recommend a fusion.  The patient was a smoker and had been advised to quit smoking but has not quit smoking.  I have therefore recommended that he use iliac bone graft.  I explained to the patient that this would give him a scar over the back of the right pelvis and could be a source of chronic pain for the patient for the rest of his life.  Even if this type of bone graft was used, there was no guarantee that it will fuse and he should stop smoking completely.,The patient also was advised that if I did a fusion, I would also use post instrumentation, which was a wire.  The wire would be left permanently.,Even with all these procedures, there was no guarantee that his symptoms would improve.  His numbness, tingling, and weakness could get worse rather than better, his neck pain and arm pain could persist.  He still had some residual bursitis in his left shoulder and this would not be cured by this procedure.  Other procedures may be necessary later.  There is still with a danger of becoming quadriplegic or losing total control of bowel or bladder function.  He could lose total control of his arms or legs and end up in the bed for the rest of his life.  He could develop chronic regional pain syndromes.  He could get difficulty swallowing or eating.  He could have substantial weakness in the arm.  He was advised that he should not undergo the surgery unless the pain is persistent, severe, and unremitting.,He was also offered his records if he would like any other pain medications or seek other treatments, he was advised that Dr. X would continue to prescribe pain medication if he did not wish to proceed with surgery.,He stated he understood all the risks.  He did not wish to get any other treatments.  He said the pain has reached the point that he wished to proceed with surgery.,PROCEDURE IN DETAIL: , In the operating room, he was given general endotracheal anesthesia.,I then carefully rolled the patient on thoracic rolls.  His head was controlled by a horseshoe holder.  The anesthesiologist checked the eye positions to make sure there was no pressure on the orbits and the anesthesiologist continued to check them every 15 minutes.  The arms, the right hip, and the neck was then prepped and draped.  Care was taken to position both arms and both legs.  Pulses were checked.,A midline incision was made through the skin and subcutaneous tissue on the cervical spine.  A loupe magnification and headlamp illumination was used.  Bleeding vessels were cauterized.  Meticulous hemostasis was carried out throughout the procedure.  Gradually and carefully I exposed the spinous process of the C6, C5, and C4.  A lateral view was done after an instrument in place.  This revealed the C6-C7 level.  I therefore did a small laminotomy opening at C4-C5.  I placed an instrument and x-rays confirmed C4-C5 level.,I stripped the muscles from the lamina and then moved them laterally and held with a self-retaining retractor.,Once I identified the level, I then used a bur to thin the lamina of C5.  I used a 1-mm, followed by a 2-mm Kerrison rongeur to carefully remove the lamina off C5 on the left.  I removed some of the superior lamina of C6 and some of the inferior lamina of C4.  This allowed me to visualize the dura and the nerve roots and gradually do neural foraminotomies for both the C5 and C6 nerve roots.  There was some bleeding from the epidural veins and a bipolar cautery was used.  Absolutely no retractors were ever placed in the canal.  There was no retraction.  I was able to place a small probe underneath the nerve root and check the disc spaces to make sure there was no fragments of disc or herniation disc and none were found.,At the end of the procedure, the neuroforamen were widely patent.  The nerve roots had been fully decompressed.,I then checked stability.  There was micromotion at the C4-C5 level.  I therefore elected to proceed with a fusion.,I debrided the interspinous ligament between C4 and C5.  I used a bur to roughen up the surface of the superior portion of the spinous process of C5 and the inferior portion of C4.  Using a small drill, I opened the facet at C4-C5.  I then used a very small curette to clean up the articular cartilage.  I used a bur then to roughen up the lamina at C4-C5.,Attention was turned to the right and left hip, which was also prepped.  An incision made over the iliac crest.  Bleeding vessels were cauterized.  I exposed just the posterior aspect of the crest.  I removed some of the bone and then used the curette to remove cancellous bone.,I placed the Songer wire through the base of the spinous process of C4 and C5.  Drill holes made with a clip.  I then packed cancellous bone between the decorticated spinous process.  I then tightened the Songer wire to the appropriate tension and then cut off the excess wire.,Prior to tightening the wire, I also packed cancellous bone with facet at C4-C5.  I then laid bone upon the decorticated lamina of C4 and C5.,The hip wound was irrigated with bacitracin and Kantrex.  Deep structures were closed with #1 Vicryl, subcutaneous suture and subcuticular tissue was closed.,No drain was placed in the hip.,A drain was left in the posterior cervical spine.  The deep tissues were closed with 0 Vicryl, subcutaneous tissue and skin were then closed.  The patient was taken to the recovery room in good condition.
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DESCRIPTION: Decompressive left lumbar laminectomy C4-C5 and C5-C6 with neural foraminotomy. Posterior cervical fusion C4-C5.  Songer wire.  Right iliac bone graft.

The situation described involves a complex spinal surgery with multiple potential complications and inherent risks, such as paralysis, chronic pain, and failure to relieve symptoms. Given the potential for severe consequences like quadriplegia or chronic pain, and the patient's continued smoking despite having been advised to quit, the stakes are high. The decision is compounded by the fact that non-surgical options are limited, and the patient has opted for surgery due to persistent and severe pain. Therefore, this is a high-stakes medical situation given the serious nature of the surgery and potential outcomes.


Medical Specialty: Orthopedic
Sample Name: Knee Surgery - Discharge Summary

CHIEF COMPLAINT:,  Decreased ability to perform daily living activities secondary to right knee surgery.,HISTORY OF PRESENT ILLNESS: , The patient is a 61-year-old white female status post right total knee replacement secondary to degenerative joint disease performed by Dr. A at ABCD Hospital on 08/21/2007.  The patient was transfused with 2 units of autologous blood postoperatively.  She received DVT prophylaxis with a combination of Coumadin, Lovenox, SCD boots, and TED stockings.  The remainder of her postoperative course was uneventful.  She was discharged on 08/24/2007 from ABCD Hospital and admitted to the transitional care unit at XYZ Services for evaluation and rehabilitation.  The patient reports that her last bowel movement was on 08/24/2007 just prior to her discharge from ABCD Hospital.  She denies any urological symptoms such as dysuria, incomplete bladder emptying or other voiding difficulties.  She reports having some right knee pain, which is most intense at a "certain position."  The patient is unable to elaborate on which "certain position" causes her the most discomfort.,ALLERGIES:,  NKDA.,PAST MEDICAL HISTORY: , Hypertension, hypothyroidism, degenerative joint disease, GERD, anxiety disorder, Morton neuroma of her feet bilaterally, and distant history of migraine headaches some 30 years ago.,MEDICATIONS:,  On transfer, Celebrex, Coumadin, Colace, Synthroid, Lovenox, Percocet, Toprol XL, niacin, and trazodone.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 96.5, blood pressure 127/72, pulse 70, respiratory rate 20, 95% O2 saturation on room air.,GENERAL:  No acute distress at the time of the exam except as mentioned above complains of right knee pain at "certain position.",HEENT:  Normocephalic.  Sclerae nonicteric.  EOMI.  Dentition in good repair.  Tongue is in midline with no evidence of thrush.,NECK:  No thyroid enlargement.  Trachea is midline.,LUNGS:  Clear to auscultation.,HEART:  Regular rate and rhythm.  Normal S1 and S2.,ABDOMEN:  Soft, nontender, and nondistended.  No organomegaly.,EXTREMITIES:  The right knee incision is intact.  Steri-Strips are in place.  There is some diffuse right knee edema and some limited ecchymosis as well.  No calf tenderness bilaterally.  Pedal pulses are palpable bilaterally.,MENTAL STATUS:  The patient appears slightly anxious during the interview and exam, but she was alert and oriented.,HOSPITAL COURSE: , As mentioned above, the patient was admitted on 08/24/2007 to the Transitional Care Unit at XYZ Services for evaluation and rehabilitation.  She was seen in consultation by Physical Therapy and Occupational Therapy and had begun her rehabilitation till recovery.  The patient had been properly instructed regarding using the CPM machine and she had been instructed as well to limit each CPM session to two hours.  Very early in her hospitalization, the patient enthusiastically used the CPM much longer than two hours and consequently had increased right knee pain.  She remarked that she had a better degree of flexibility, but she did report an increased need for pain management.  Additionally, she required Ativan and at one point scheduled the doses of Ativan to treat her known history of anxiety disorder.  On the fourth hospital day, she was noted to have some rashes about the right upper extremity and right side of her abdomen.  The patient reported that this rash was itchy.  She reports that she had been doing quite a bit of gardening just prior to surgery and this was most likely contact dermatitis, most likely due to her gardening activities preoperatively.  She was treated with betamethasone cream applied to the rash b.i.d.  The patient's therapy had progressed and she continued to make a good progress.  At one point, the patient reported some insomnia due to right knee pain.  She was switched from Percocet to oxycodone SR 20 mg b.i.d. and she had good pain control with this using the Percocet only for breakthrough pain.  The DVT prophylaxis was maintained with Lovenox 40 mg subcu daily until the INR was greater than 1.7 and it was discontinued on 08/30/2007 when the INR was 1.92 within therapeutic range.  The Coumadin was adjusted accordingly according to the INRs during her hospital course.  Early in the hospital course, the patient had reported right calf tenderness and a venous Doppler study obtained on 08/27/2007 showed no DVT bilaterally.  Initial laboratory data includes a UA on 08/28/2007, which was negative.  Additionally, CBC showed a white count of 6.3, hemoglobin was 12.1, hematocrit was 35.3, and platelets were 278,000.  Chemistries were within normal limits.  Creatinine was 0.8, BUN was 8, anion gap was slightly decreased at 5, fasting glucose was 102.  The remainder of chemistries was unremarkable.  The patient continued to make great progress with her therapies so much so that we are anticipating her discharge on Monday, 09/03/2007.,DISCHARGE DIAGNOSES:,1.  Status post right total knee replacement secondary to degenerative joint disease performed on 08/21/2007.,2.  Anxiety disorder.,3.  Insomnia secondary to pain and anxiety postoperatively.,4.  Postoperative constipation.,5.  Contact dermatitis secondary to preoperative gardening activities.,6.  Hypertension.,7.  Hypothyroidism.,8.  Gastroesophageal reflux disease.,9.  Morton neuroma of the feet bilaterally.,10.  Distant history of migraine headaches.,INSTRUCTIONS GIVEN TO THE PATIENT AT THE TIME OF DISCHARGE: , The patient is advised to continue taking the following medications:  Celebrex 200 mg daily, for one month, Colace 100 mg b.i.d. for one month, Protonix 40 mg b.i.d. for one month, Synthroid 137 mcg daily, Diprosone cream 0.05% cream b.i.d. to the right arm and right abdomen, oxycodone SR 20 mg p.o. q.12h. for five days, then decrease to oxycodone SR 10 mg p.o. q.12h. for five days, Percocet 5/325 mg one to two tablets q.6h. to be used p.r.n. for breakthrough pain, trazodone 50 mg p.o. at bedtime p.r.n. for two weeks, Ativan 0.25 mg b.i.d. for two weeks, and Toprol-XL 50 mg daily.  The patient will also take Coumadin and the dose will be adjusted according to the INRs, which will be obtained every Monday and Thursday with results being sent to Dr. A and his fax number is 831-5926.  At the present time, the patient is taking Coumadin 7 mg daily.  She will remain on Coumadin for 30 days.  An INR is to be obtained on 09/03/2007 and should the Coumadin dose be changed, an addendum will be dictated to accompany this discharge summary.  Finally, the patient has a followup appointment with Dr. A on 09/21/2007 at noon at his office.  The patient is encouraged to follow up with her primary care physician, Dr. B.  As mentioned above, the patient will be discharged on 09/03/2007 in stable and improved condition since she is status post right total knee replacement and has made good progress with her therapies and rehabilitation.
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DESCRIPTION: Decreased ability to perform daily living activities secondary to right knee surgery.

This situation involves the discharge summary of a patient who underwent a total knee replacement—a common orthopedic procedure. While it requires careful post-operative management to ensure proper recovery, potential complications (such as DVT or infection) have been effectively managed according to the summary. The patient is being discharged with a comprehensive medication plan and follow-up appointments, indicating that the medical team's concerns have been addressed. However, considering the patient's multiple comorbidities, ongoing pain management, and reliance on anticoagulation, this scenario involves a moderate level of stakes typical of post-operative orthopedic care.


Medical Specialty: Orthopedic
Sample Name: Knee Injury

HISTORY OF PRESENT ILLNESS: , The patient is an 18-year-old girl brought in by her father today for evaluation of a right knee injury.  She states that approximately 3 days ago while playing tennis she had a non-contact injury in which she injured the right knee.  She had immediate pain and swelling.  At this time, she complains of pain and instability in the knee.  The patient's past medical history is significant for having had an ACL injury to the knee in 2008.  She underwent anterior cruciate ligament reconstruction by Dr. X at that time, subsequently in the same year she developed laxity of the graft due in part to noncompliance and subsequently, she sought attention from Dr. Y who performed a revision ACL reconstruction at the end of 2008.  The patient states she rehabbed the knee well after that and did fine with good stability of the knee until this recent injury.,PAST MEDICAL HISTORY:,  She claims no chronic illnesses.,PAST SURGICAL HISTORY: , She had an anterior cruciate ligament reconstruction in 03/2008, and subsequently had a revision ACL reconstruction in 12/2008.  She has also had arm surgery when she was 6 years old.,MEDICATIONS: , She takes no medications on a regular basis,ALLERGIES: , She is allergic to Keflex and has skin sensitivity to Steri-Strips.,SOCIAL HISTORY:  ,The patient is single.  She is a full-time student at University.  Uses no tobacco, alcohol, or illicit drugs.  She exercises weekly, mainly tennis and swelling.,REVIEW OF SYSTEMS:  ,Significant for recent weight gain, occasional skin rashes.  The remainder of her systems negative.,PHYSICAL EXAMINATION,GENERAL:  The patient is 4 foot 10 inches tall, weighs 110 pounds.,EXTREMITIES:  She ambulates with some difficulty with a marked limp on the right side.  Inspection of the knee reveals a significant effusion in the knee.  She has difficulty with passive range of motion of the knee secondary to pain.  She does have tenderness to palpation at the medial joint line and has a positive Lachman's exam.,NEUROVASCULAR:  She is neurovascularly intact.,IMPRESSION: , Right knee injury suggestive of a recurrent anterior cruciate ligament tear, possible internal derangement.,PLAN: , The patient will be referred for an MRI of the right knee to evaluate the integrity of her revision ACL graft.  In the meantime, she will continue to use ice as needed.  Moderate her activities and use crutches.  She will follow up as soon as the MRI is performed.
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DESCRIPTION: Right knee injury suggestive of a recurrent anterior cruciate ligament tear, possible internal derangement.  While playing tennis she had a non-contact injury in which she injured the right knee.  She had immediate pain and swelling.

orthopedic, acl graft, acl reconstruction, knee, anterior cruciate ligament, internal derangement, contact injury, knee injury, injury, cruciate, acl, anterior,

The situation involves a potential recurrent ACL injury in a young, active patient. While the injury is significant, it is not immediately life-threatening. ACL injuries can have substantial long-term implications for mobility and sports participation, especially considering the patient's history of surgeries. Proper management and diagnosis are essential to prevent further complications and ensure recovery, but these factors do not elevate it to the highest stakes level in medical emergencies.


Medical Specialty: Orthopedic
Sample Name: Knee DJD - Consult

CHIEF COMPLAINT: , Left knee pain and stiffness.,HISTORY OF PRESENT ILLNESS: , The patient is a 57-year-old with severe bilateral knee DJD, left greater than right, with significant pain and limitations because of both.  He is able to walk approximately a 1/2-mile a day but is limited because of his knees.  Stairs are negotiated 1 at a time.  His problems with bilateral knee DJD have been well documented.  He had arthroscopy in the 1991/199two time frame for both of these.  He has been on long-standing conservative course for these including nonsteroidals, narcotics, injections.  At this point because of his progressive and persistent limitations he has opted for total joint surgery on the left side.  He does have other arthritic complaints including multiple back surgeries for spinal stenosis including decompression and epidural steroids.  Significant pain is handled by narcotic medication.  His attending physician is Dr. X.,PAST MEDICAL HISTORY: , Hypertension.,PRIOR SURGERIES:,1.  Inguinal hernia on the left.,2.  Baker's cyst.,3.  Colon cancer removal.,4.  Bilateral knee scopes.,5.  Right groin hernia.,6.  Low back surgery for spinal stenosis.,7.  Status post colon cancer second surgery.,MEDICATIONS:,1.  Ambien 12.5 mg nightly.,2.  Methadone 10 mg b.i.d.,3.  Lisinopril 10 mg daily.,IV MEDICATIONS FOR PAIN:  ,Demerol appears to work the best.,ALLERGIES: , Levaquin and Cipro cause rashes; ibuprofen causes his throat to swell, Fortaz causes an unknown reaction.,REVIEW OF SYSTEMS:  ,He does have paresthesias down into his thighs secondary to spinal stenosis.,SOCIAL HISTORY: , Married.  He is retired, being a Pepsi-Cola driver secondary to his back and knees.,HABITS: , No tobacco or alcohol.  Chewed until 2003.,RECREATIONAL PURSUITS:  ,Golfs, gardens, woodworks.,FAMILY HISTORY:,1.  Cancer.,2.  Coronary artery disease.,PHYSICAL EXAMINATION:,GENERAL APPEARANCE:  A pleasant, cooperative 57-year-old white male.,VITAL SIGNS:  Height 5' 9", weight 167.  Blood pressure 148/86.  Pulse 78 per minute and regular.,HEENT:  Unremarkable.  Extraocular movements are full.  Cranial nerves II-XII intact.,NECK:  Supple.,CHEST:  Clear.,CARDIOVASCULAR:  Regular rhythm.  Normal S1 and 2.,ABDOMEN:  No organomegaly.  No tenderness.  Normal bowel sounds.,NEUROLOGIC:  Intact.,MUSCULOSKELETAL:  Left knee reveals a range of -10 degrees extension, 126 flexion.  His extensor mechanism is intact.  There is mild varus.  He has good stability at 30 degrees of flexion.  Lachman's and posterior drawer are negative.  He has good muscle turgor.  Dorsalis pedis pulse 2+.,DIAGNOSTICS:  ,X-rays revealed severe bilateral knee DJD with joint space narrowing medially as well as the patellofemoral joint with large osteophytes, left greater than right.,IMPRESSION:,1.  Bilateral knee degenerative joint disease.,2.  Significant back pain, status post lumbar stenosis surgery with pain being controlled on methadone 10 mg b.i.d.
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DESCRIPTION: Left knee pain and stiffness.  Bilateral knee degenerative joint disease (DJD).  Significant back pain, status post lumbar stenosis surgery with pain being controlled on methadone 10 mg b.i.d.

The situation involves a 57-year-old patient with severe bilateral knee degenerative joint disease (DJD), significant knee pain, and history of multiple surgeries, including back surgery for spinal stenosis. The patient has opted for total joint surgery on the left knee due to progressive and persistent limitations. While the patient's daily functioning is affected by the knee pain and stiffness, the condition is chronic and management plans like surgery have been made. Since the medical situation is pre-planned and under control with a guided surgical path, it suggests that while the situation is important for the patient's quality of life, it's not an immediate life-and-death situation. The stakes are moderate as successful recovery from surgery could significantly impact the patient's mobility and quality of life.


Medical Specialty: Orthopedic
Sample Name: Knee & Back Pain

REASON FOR EVALUATION:,
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DESCRIPTION: Evaluation for chronic pain program

Evaluation for chronic pain program

The evaluation for knee and back pain, particularly in the context of a chronic pain program, suggests the situation involves ongoing management rather than an immediate life-threatening emergency. While chronic pain can significantly affect a patient's quality of life, it is generally not considered as high-stakes as acute or life-threatening medical issues. The stakes are important for the patient's long-term wellbeing and functional mobility, which is significant but not critical in a life or death sense.


Medical Specialty: Orthopedic
Sample Name: IME & Record Review - Orthopedic

INTRODUCTION: , The opinions expressed in this report are those of the physician.  The opinions do not reflect the opinions of Evergreen Medical Panel, Inc.  The claimant was informed that this examination was at the request of the Washington State Department of Labor and Industries (L&I).  The claimant was also informed that a written report would be sent to L&I, as requested in the assignment letter from the claims manager.  The claimant was also informed that the examination was for evaluative purposes only, intended to address specific injuries or conditions as outlined by L&I, and was not intended as a general medical examination.,CHIEF COMPLAINTS: , This 51-year-old married male presents complaining of some right periscapular discomfort, some occasional neck stiffness, and some intermittent discomfort in his low back relative to an industrial fall that occurred on November 20, 2008.,HISTORY OF INDUSTRIAL INJURY:,  This patient was injured on November 20, 2008.  He works at the Purdy Correctional Facility and an inmate had broken some overhead sprinklers, the floor was thus covered with water and the patient slipped landing on the back of his head, then on his back.  The patient said he primarily landed on the left side.  After the accident he states that he was generally stun and someone at the institute advised him to be evaluated.  He went to a Gig Harbor urgent care facility and they sent him on to Tacoma General Hospital.  At the Tacoma General, he indicates that a whiplash and a concussion were diagnosed and it was advised that he have a CT scan.  The patient describes that he had a brain CT and a dark spot was found.  It was recommended that he have a followup MRI and this was done locally and showed a recurrent acoustic neuroma.  Before, when the patient initially had developed an acoustic neuroma, the chiropractor had seen the patient and suggested that he have a scan and this was how his original acoustic neuroma was diagnosed back in October 2005.  The patient has been receiving adjustments by the chiropractor since and he also has had a few massage treatments.  Overall his spine complaints have improved substantially.,After the fall, he also saw at Prompt Care in the general Bremerton area, XYZ, an Osteopathic Physician and she examined him and released him full duty and also got an orthopedic consult from XYZ.  She ordered an MRI of his neck.  Cervically this showed that he had a mild disc bulge at C4-C5, but this actually was the same test that diagnosed a recurrent acoustic neuroma and the patient now is just recovering from neurosurgical treatment for this recurrent acoustic neuroma and some radiation is planned.,Since 2002 the patient has been seeing the chiropractor, XYZ for general aches and pain and this has included some treatments on his back and neck.,CURRENT SYMPTOMS:  ,The patient describes his current pain as being intermittent.,PAST MEDICAL HISTORY:,Illnesses:  The patient had a diagnosis in 2005 of an acoustic neuroma.  It was benign, but treated neurosurgically.  In February 2004 and again in August 2009 he has had additional treatments for recurrence and he currently has some skull markers in place because radiation is planned as a followup, although the tumor was still indicated to be benign.,Operations:  He has a history of an old mastoidectomy.  He has a past history of removal of an acoustic neuroma in 2005 as noted.,Medications:  The patient takes occasional Tylenol and occasional Aleve.,Substance Use:,Tobacco:  He does not smoke cigarettes.,Alcohol:  He drinks about five beers a week.,FAMILY HISTORY:,  His father died of mesothelioma and his mother died of Lou Gehrig's disease.,SOCIOECONOMIC HISTORY:,Marital Status and Dependents:  The patient has been married three times; longest marriage is of two years duration.  He has two children.  These dependents are ages 15 and twins and are his wife's dependents.,Education:  The patient has bachelor's degree.,Military History:  He served six years in the army and received an honorable discharge.,Work History:  He has worked at Purdy Correctional Institute in Gig Harbor for 19 years.,CHART REVIEW: , Review of the chart indicates a date of injury of November 20, 2008.  He was seen at Tacoma General Hospital with a diagnosis of head contusion and cervical strain.  He had a CT of his head done because of a fall with possible loss of consciousness, which showed a left cerebellar hypodensity and further evaluation was recommended.  He has a history of an old mastoidectomy.  He was then seen on November 24, 2008 by XYZ at Prompt Care on November 24, 2008.  There is no clearcut history that he had lost consciousness.  He has a past history of removal of an acoustic neuroma in 2005 as noted.  A diagnosis of concussion and cervical strain status post fall was made along with an underlying history of abnormal CT and previous resection of an acoustic neuroma.  Some symptoms of loss of balance and confusion were noted.  She recommended additional testing and neurologic evaluation.,The notes from the treating chiropractor begin on November 24, 2008.  Adjustments are given to the cervical, thoracic, and lumbar spine.,He was seen back by XYZ on December 9, 2008 and he had been released to full duties.  It was recognized the new MRI suggested recurrence of the acoustic neuroma and he was advised to seek further care in this regard.  There were some concerns of his feeling of being wobbly since the fall which might be related to the recurrent neuroma.  He continued to have chiropractic adjustments.  He was seen back at Prompt Care on January 8, 2009.  Dr. X indicated that she thought most of his symptoms were related to the tumor, but that the cervical and thoracic stiffness were from the fall.,A followup note by his chiropractor on January 26, 2009 indicates that cervical x-rays have been taken and that continued chiropractic adjustments along with manual traction would be carried out.,On April 13, 2009, he was seen again at Prompt Care for his cervical and thoracic strain.  He was indicated to be improving and there was suggestion that he has some physical therapy and an orthopedic consult was felt appropriate.  Therapy was not carried out and obviously was then involved with the treatment of his recurrent neuroma.,On April 17, 2009, he was seen by Dr. X, another chiropractor for consultation and further chiropractic treatments were recommended based on cervical and thoracolumbar subluxation complexes and strain.,A repeat consult was carried out on April 29, 2009 by XYZ.  He felt that this was hyperextension cervical injury.  It might take a period of time to recover.  He mentioned that the patient might have a slight ulnar neuropathy.  He felt the patient was capable of full duty and the patient was at that time having ongoing treatment for his neuroma.,This concludes the chart review.,PHYSICAL EXAMINATION: , The patient is 6 feet in height, weighs 255 pounds.,Orthopedic Examination:  He can walk with a normal gait, but he has, as indicated, a positive Romberg test and he himself has noticed that if he closes his eyes he loses his balance.  Overall the patient is a seemingly good historian.  There is a visible 3 cm scar at the left base of the neck near the hairline and there are multiple areas where his head has been shaved both anteriorly and posteriorly.  These are secondary to drawing for the skull markers.  There is a scar behind the patient's left ear from the original treatment of the acoustic neuroma.  This was well healed.  The patient can perform a toe-heel gait without difficulty.  One visibly can see that he has some facial asymmetry and he indicates that the acoustic neuroma has caused some numbness in the left side of his face and also some asymmetry that is now recovering.  The patient states he now thinks his recovery is going to get disregarded and that the facial asymmetry and numbness developed from the first surgery he had.  The patient has a full range of motion in both of his shoulders.  The patient has a full range of motion in his lumbar spine to include 90 degrees of forward bend, lateral bending of 30 degrees in either direction and extension of 10 degrees.  There is full range of motion in the patient's cervical spine to include flexion of 50 degrees at which time he can touch his chin on his chest.  He extends 40 degrees, laterally bends 30 degrees, and rotates to 80 degrees in either direction.  There is slight tenderness on palpating over the right cervical musculature.  There is no evidence of any cervical or lumbar muscle spasms.  Reflexes in the upper extremities include 1+ biceps and triceps and 1+ brachioradialis.  Knee jerks are 2+ and ankle jerks are 1+.  Tinel's test was tested at the elbow, it is negative bilaterally with percussion; however, he has slight tingling bilaterally.  The patient's grip tested with a Jamar dynamometer increases from 70 to 80 pounds bilaterally.  Sensory testing of lower extremities reveal that the patient has slightly decreased sensation to sharp stimulus in his dorsal aspect of the right first toe and a lesser extent to the left.  Testing of muscle strength in the upper and lower extremities is normal.  The patient upper arms measured four fingerbreadths above the flexion crease of the elbow measure 35 cm bilaterally.  The forearms measured four fingerbreadths below the flexion crease of the elbow measure 30 cm bilaterally.  The thighs measured four fingerbreadths above the superior pole of the patella measure 48 cm and the lower legs measured four fingerbreadths below the tibial tubercles measure 41 cm.  Pressure on the vertex of the head does not bother the patient.  Axial loading is negative.  As already indicated straight leg raising is entirely negative both sitting and lying for any radiculitis.,DIAGNOSTIC STUDIES: , X-rays the patient brings with him taken by his treating chiropractor dated 11/24/08 showed that there appears to be a little bit of narrowing of the L4-5 disc space.  The hip joints are normal.  Views of his thoracic spine are normal.  Cervical x-rays are in the file.  These are of intermittent quality, but the views do show a very slight degree of anterior spurring at the C4-5 with possible slight narrowing of the disc.  There is a view of the right shoulder that is unremarkable.,CONCLUSIONS:,  The accepted condition under the claim is a sprain of the neck, thoracic, and lumbar.,DIAGNOSES: , Diagnosis based on today's examination is a sprain of the cervical spine and lumbar spine superimposed upon some early degenerative changes.,Additional diagnosis is one of recurrent acoustic neuroma, presumably benign with upcoming additional treatment of radiation plan.  The patient also has a significant degree overweight for his height and it will be improved as he himself recognizes by some weight loss and exercise.,DISCUSSION: , He is fixed and stable at this time and his industrial case can be closed relative to his industrial injury of November 20, 2008.  Further chiropractic treatments would be entirely palliative and serve no additional medical purpose due to the fact that he has very minimal symptoms and a basis for these symptoms based on mild or early degenerative changes in both cervical and lumbar spine.  He is category I relative to the cervical spine under 296-20-240 and category I to the lumbosacral spine under WAC 296-20-270.  His industrial case should be closed and there is, as indicated, no basis for any disability award.
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DESCRIPTION: A male presents complaining of some right periscapular discomfort, some occasional neck stiffness, and some intermittent discomfort in his low back relative to an industrial fall.

The situation described involves a non-life-threatening medical condition stemming from an industrial fall and a pre-existing neuroma. While the claimant has experienced various symptoms, they appear to be manageable, and the condition has been deemed fixed and stable by the physician. The case is to be closed without any further significant medical intervention anticipated from the industrial injury. The stakes are not high as there is no immediate threat to life or function, and the symptoms are mild and stable according to the report.


Medical Specialty: Orthopedic
Sample Name: Hip Surgery - Discharge Summar

CHIEF COMPLAINT:,  Decreased ability to perform daily living activity secondary to recent right hip surgery.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 51-year-old white female who is status post right total hip replacement performed on 08/27/2007 at ABCD Hospital by Dr. A.  The patient had an unremarkable postoperative course, except low-grade fever of 99 to 100 postoperatively.  She was admitted to the Transitional Care Unit on 08/30/2007 at XYZ Services.  Prior to her discharge from ABCD Hospital, she had received DVT prophylaxis utilizing Coumadin and Lovenox and the INR goal is 2.0 to 3.0.  She presents reporting that her last bowel movement was on 08/26/2007 prior to surgery.  Otherwise, she reports some intermittent right calf discomfort and some postoperative right hip pain.,ALLERGIES:,  No known drug allergies.,PAST MEDICAL HISTORY:,  Anxiety, depression, osteoarthritis, migraine headaches associated with menstrual cycle, history of sciatic pain in the distant past, history of herniated disc, and status post appendectomy.,MEDICATIONS:  ,Medications taken at home are Paxil, MOBIC, and Klonopin.,MEDICATIONS ON TRANSFER: , Celebrex, Coumadin, Colace, Fiorinal, oxycodone, Klonopin, and Paxil.,FAMILY HISTORY:,  Noncontributory.,SOCIAL HISTORY: , The patient is married.  She lives with her husband and is employed as a school nurse for the School Department.  She had quit smoking cigarettes some 25 years ago and is a nondrinker.,REVIEW OF SYSTEMS:,  As mentioned above.  She has a history of migraine headaches associated with her menstrual cycle.  She wears glasses and has a history of floaters.  She reports a low-grade temperature of 99 to 100 postoperatively, mild intermittent cough, scratchy throat, (the symptoms may be secondary to intubation during surgery), intermittent right calf pain, which was described as sharp, but momentary with a negative Homans sign.  The patient denies any cardiopulmonary symptoms such as chest pain, palpitation, pain in the upper neck and down to her arm, difficulty breathing, shortness of breath, or hemoptysis.  She denies any nausea, vomiting, or diarrhea, but reports as being constipated with the last bowel movement being on 08/26/2007 prior to surgery.  She denies urinary symptoms such as dysuria, urinary frequency, incomplete bladder emptying or voiding difficulties.  First day of her last menstrual cycle was 08/23/207 and she reports that she is most likely not pregnant since her husband had a vasectomy years ago.,PHYSICAL EXAMINATION:,VITAL SIGNS:  At the time of admission, temperature 97.7, blood pressure 108/52, heart rate 94, respirations 18, and 95% O2 saturation on room air.,GENERAL:  No acute distress at the time of exam.,HEENT:  Normocephalic.  Sclerae are nonicteric.  EOMI.  Dentition is in good repair.,NECK:  Trachea is at the midline.,LUNGS:  Clear to auscultation.,HEART:  Regular rate and rhythm.,ABDOMEN:  Bowel sounds are heard throughout.  Soft and nontender.,EXTREMITIES:  Right hip incision is clean, intact, and no drainage is noted.  There is diffuse edema, which extends distally.  There is no calf tenderness per se bilaterally and Homans sign is negative.  There is no pedal edema.,MENTAL STATUS:  Alert and oriented x3, pleasant and cooperative during the exam.,LABORATORY DATA: , Initial workup included chemistry panel, which was unremarkable with the exception of a fasting glucose of 122 and an anion gap that was slightly decreased at 6.  The BUN was normal at 8, creatinine was 0.9, INR was 1.49.  CBC, had a white count of 5.7, hemoglobin was 9.2, hematocrit was 26.6, and platelets were 318,000.,IMPRESSION:,1.  Status post right total hip replacement.  The patient is admitted to the TCU at XYZ's Health Services and will be seen in consultation by Physical Therapy and Occupational Therapy.,2.  Postoperative anemia, Feosol 325 mg one q.d.,3.  Pain management.  Oxycodone SR 20 mg b.i.d., and oxycodone IR 5 mg one to two tablets q.4h., p.r.n. pain.  Additionally, she will utilize ice to help decrease edema.,4.  Depression and anxiety, Paxil 40 mg daily, Klonopin 1 mg q.h.s.,5.  Osteoarthritis, Celebrex 200 mg b.i.d.,6.  GI prophylaxis, Protonix 40 mg b.i.d.  Dulcolax suppository and lactulose will be used as a p.r.n. basis and Colace 100 mg b.i.d.,7.  DVT prophylaxis will be maintained with Arixtra 2.5 mg subcutaneously daily until the INR is greater than 1.7 and Coumadin will be adjusted according to the INR.  She will continue on 5 mg every day.,8.  Right leg muscle spasm/calf pain is stable at this time and we will reevaluate on a regular basis.  Monitor for any possibility of DVT.
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DESCRIPTION: Decreased ability to perform daily living activity secondary to recent right hip surgery.

The situation involves a medical discharge summary for a patient who recently underwent right total hip replacement. The stakes involve ensuring proper postoperative care, including monitoring for complications like DVT, managing pain, and addressing postoperative anemia. While these are important for the patient's recovery, they are part of routine postoperative care and are not typically considered high-stakes unless complications arise. The patient is under medical supervision and the case does not involve immediate life-threatening situations.


Medical Specialty: Orthopedic
Sample Name: Hip Fracture - Rehab Consult

ADMISSION DIAGNOSIS: , Left hip fracture.,CHIEF COMPLAINT: , Diminished function, secondary to the above.,HISTORY: , This pleasant 70-year-old gentleman had a ground-level fall at home on 05/05/03 and was brought into ABCD Medical Center, evaluated by Dr. X and brought in for orthopedic stay.  He had left hip fracture identified on x-rays at that time.  Pain and inability to ambulate brought him in.  He was evaluated and then underwent medical consultation as well, where they found a history of resolving pneumonia, hypertension, chronic obstructive pulmonary disease, congestive heart failure, hypothyroidism, depression, anxiety, seizure and chronic renal failure, as well as anemia.  His medical issues are under good control.  The patient underwent left femoral neck fixation with hemiarthroplasty on that left side on 05/06/03.  The patient has had some medical issues including respiratory insufficiency, perioperative anemia, pneumonia, and hypertension.  Cardiology has followed closely, and the patient has responded well to medical treatment, as well as physical therapy and occupational therapy.  He is gradually tolerating more activities with less difficulties, made good progress and tolerated more consistent and more prolonged interventions.,PAST MEDICAL HISTORY: , Positive for congestive heart failure, chronic renal insufficiency, azotemia, hyperglycemia, coronary artery disease, history of paroxysmal atrial fibrillation.  Remote history of subdural hematoma precluding the use of Coumadin.  History of depression, panic attacks on Doxepin.  Perioperative anemia.  Swallowing difficulties.,ALLERGIES:,  Zyloprim, penicillin, Vioxx, NSAIDs.,CURRENT MEDICATIONS,1.  Heparin.,2.  Albuterol inhaler.,3.  Combivent.,4.  Aldactone.,5.  Doxepin.,6.  Xanax.,7.  Aspirin.,8.  Amiodarone.,9.  Tegretol.,10.  Synthroid.,11.  Colace.,SOCIAL HISTORY: , Lives in a 1-story home with 1 step down; wife is there.  Speech and language pathology following with current swallowing dysfunction.  He is minimum assist for activities of daily living, bed mobility.,REVIEW OF SYSTEMS:,  Currently negative for headache, nausea and vomiting, fevers, chills or shortness of breath or chest pain.,PHYSICAL EXAMINATION,HEENT:  Oropharynx clear.,CV:  Regular rate and rhythm without murmurs, rubs or gallops.,LUNGS:  Clear to auscultation bilaterally.,ABDOMEN:  Nontender, nondistended.  Bowel sounds positive.,EXTREMITIES:  Without clubbing, cyanosis, or edema.,NEUROLOGIC:  There are no focal motor or sensory losses to the lower extremities.  Bulk and tone normal in the lower extremities.  Wound site has healed well with staples out.,IMPRESSION ,1.  Status post left hip fracture and hemiarthroplasty.,2.  History of panic attack, anxiety, depression.,3.  Myocardial infarction with stent placement.,4.  Hypertension.,5.  Hypothyroidism.,6.  Subdural hematoma.,7.  Seizures.,8.  History of chronic obstructive pulmonary disease.  Recent respiratory insufficiency.,9.  Renal insufficiency.,10.  Recent pneumonia.,11.  O2 requiring.,12.  Perioperative anemia.,PLAN: , Rehab transfer as soon as medically cleared.
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DESCRIPTION: Status post left hip fracture and hemiarthroplasty.   Rehab transfer as soon as medically cleared.

The patient is recovering from a significant surgical procedure (left femoral neck fixation with hemiarthroplasty) following a hip fracture. The medical history is complex, including serious conditions such as congestive heart failure, chronic renal failure, a history of myocardial infarction, and respiratory issues like recent pneumonia. Managing these conditions properly is critical to ensuring a smooth recovery, minimizing pain, and enabling rehabilitation. Although the patient is showing progress, the stakes are high to ensure that no setbacks occur, which could significantly impair recovery and function. The overall situation requires careful coordination of orthopedic and medical care, making it moderate to high-stakes.


Medical Specialty: Orthopedic
Sample Name: Hand Pain - Consult

REASON FOR VISIT:  ,New patient visit for right hand pain.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 28-year-old right-hand dominant gentleman, who punched the wall 3 days prior to presentation.  He complained of ulnar-sided right hand pain and was seen in the emergency room.  Reportedly, he had some joints in his hand pushed back and placed by somebody in emergency room.  Today, he admits that his pain is much better.  Currently, since that time he has been in the splint with minimal pain.  He has had no numbness, tingling or other concerning symptoms.,PAST MEDICAL HISTORY:, Negative.,SOCIAL HISTORY:  ,The patient is a nonsmoker and does not use illegal drugs.  Occasionally drinks.,REVIEW OF SYSTEMS: , A 12-point review of systems is negative.,MEDICATIONS:,  None.,ALLERGIES: , No known drug allergies.,FINDINGS: , On physical exam, he has swelling and tenderness over the ulnar dorsum of his hand.  He has a normal cascade.  He has 70 degrees of MCP flexion and full IP flexion and extension.  He has 3 to 5 strength in his grip and intrinsics.  He has intact sensation to light touch in the radial, ulnar, and median nerve distribution.  Two plus radial pulse.,X-rays taken from today were reviewed, include three views of the right hand.  They show possible small fractures of the base of the fourth and third metacarpals.  Joint appears to be located.  A 45-degree oblique view was obtained and confirmed adduction of the CMC joints of the fourth and fifth metacarpals.  His injury films from 09/15/07 were reviewed and demonstrated what appears to be CMC dislocations of the third and fourth metacarpals.,ASSESSMENT: , Status post right third and fourth metacarpal carpometacarpal dislocations.,PLANS: , The patient was placed into a short-arm cast and intrinsic plus.  I would like him to wear this for 2 weeks and then follow up with us.  At that time, we will transition him to an OT splint and begin range of motion activities of the fingers and wrist.  We should see him back in 2 weeks' time at which time he should obtain three views of the right hand and a 45-degree oblique view out of cast.
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DESCRIPTION: New patient visit for right hand pain.  Punched the wall 3 days prior to presentation, complained of ulnar-sided right hand pain, and was seen in the emergency room.

orthopedic, hand pain, pain, hand, metacarpals

The situation involves a new patient with a hand injury following an altercation with a wall. While hand injuries can affect quality of life and functionality, the patient shows improvement in pain levels and no concerning symptoms like numbness or tingling. The treatment plan is straightforward with a short-arm cast and scheduled follow-ups. This is a typical orthopedic case and does not suggest a life-threatening or severely debilitating situation.


Medical Specialty: Orthopedic
Sample Name: Ganglion Excision

PREOPERATIVE DIAGNOSIS: , Ganglion of the left wrist.,POSTOPERATIVE DIAGNOSIS: , Ganglion of the left wrist.,OPERATION: , Excision of ganglion.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Less than 5 mL.,OPERATION: , After a successful anesthetic, the patient was positioned on the operating table.  A tourniquet applied to the upper arm.  The extremity was prepped in a usual manner for a surgical procedure and draped off.  The superficial vessels were exsanguinated with an elastic wrap and the tourniquet was then inflated to the usual arm pressure.  A curved incision was made over the presenting ganglion over the dorsal aspect of the wrist.  By blunt and sharp dissection, it was dissected out from underneath the extensor tendons and the stalk appeared to arise from the distal radiocapitellar joint and the dorsal capsule was excised along with the ganglion and the specimen was removed and submitted.  The small superficial vessels were electrocoagulated and instilled after closing the skin with 4-0 Prolene, into the area was approximately 6 to 7 mL of 0.25 Marcaine with epinephrine.  A Jackson-Pratt drain was inserted and then after the tourniquet was released, it was kept deflated until at least 5 to 10 minutes had passed and then it was activated and then removed in the recovery room.  The dressings applied to the hand were that of Xeroform, 4x4s, ABD, Kerlix, and elastic wrap over a volar fiberglass splint.  The tourniquet was released.  Circulation returned to the fingers.  The patient then was allowed to awaken and left the operating room in good condition.
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DESCRIPTION: Excision of ganglion of the left wrist.  A curved incision was made over the presenting ganglion over the dorsal aspect of the wrist.

orthopedic, curved incision, superficial vessels, tourniquet, excision, dorsal, wrist, ganglion

The details provided describe a surgical procedure for the excision of a ganglion cyst in the wrist, which is typically a routine and low-risk orthopedic surgery. The use of general anesthesia and the description of care and monitoring during the procedure do add some complexity, but the estimated blood loss is minimal, and the postoperative outcome indicates the patient left in good condition. The procedure is standard in nature and not life-threatening, which makes it a lower-stakes situation within a controlled surgical environment.


Medical Specialty: Orthopedic
Sample Name: Followup Screw Fixation

REASON FOR VISIT:  ,Followup 4 months status post percutaneous screw fixation of a right Schatzker IV tibial plateau fracture and second through fifth metatarsal head fractures treated nonoperatively.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 59-year-old gentleman who is now approximately 4 months status post percutaneous screw fixation of Schatzker IV tibial plateau fracture and nonoperative management of second through fifth metatarsal head fractures.  He is currently at home and has left nursing home facility.  He states that his pain is well controlled.  He has been working with physical therapy two to three times a week.  He has had no drainage or fever.  He has noticed some increasing paresthesias in his bilateral feet but has a history of spinal stenosis with lower extremity neuropathy.,FINDINGS: , On physical exam, his incision is near well healed.  He has no effusion noted.  His range of motion is 10 to 105 degrees.  He has no pain or crepitance.  On examination of his right foot, he is nontender to palpation of the metatarsal heads.  He has 4 out of 5 strength in EHL, FHL, tibialis, and gastroc-soleus complex.  He does have decreased sensation to light touch in the L4-L5 distribution of his feet bilaterally.,X-rays taken including AP and lateral of the right knee demonstrate a healed medial tibial plateau fracture status post percutaneous screw fixation.  Examination of three views of the right foot demonstrates the second through fifth metatarsal head fractures.  These appear to be extraarticular.  They are all in a bayonet arrangement, but there appears to be bridging callus between the fragments on the oblique film.,ASSESSMENT:  ,Four months status post percutaneous screw fixation of the right medial tibial plateau and second through fifth metatarsal head fractures.,PLANS: , I would like the patient to continue working with physical therapy.  He may be weightbearing as tolerated on his right side.  I would like him to try to continue to work to gain full extension of the right knee and increase his knee flexion.  I also would like him to work on ambulation and strengthening.,I discussed with the patient his concerning symptoms of paresthesias.  He said he has had the left thigh for a number of years and has been followed by a neurologist for this.  He states that he has had some right-sided paresthesias now for a number of weeks.  He claims he has no other symptoms of any worsening stenosis.  I told him that I would see his neurologist for evaluation or possibly a spinal surgeon if his symptoms progress.,The patient should follow up in 2 months at which time he should have AP and lateral of the right knee and three views of the right foot.
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DESCRIPTION: Followup 4 months status post percutaneous screw fixation of a right Schatzker IV tibial plateau fracture and second through fifth metatarsal head fractures treated nonoperatively.

orthopedic, metatarsal head fractures, tibial plateau fracture, schatzker, percutaneous screw fixation, tibial plateau, metatarsal head, screw fixation, head, screw, fixation, metatarsal

The situation involves a follow-up appointment for a patient 4 months after orthopedic surgery. The patient is recovering well, with controlled pain and regular physical therapy, and there are no immediate concerning symptoms that require urgent intervention. However, there is some concern about paresthesias, potentially linked to a history of spinal stenosis and neuropathy, but this is not directly related to the orthopedic issues. The follow-up recommendations are standard and preventative, focusing on therapy and monitoring. While paresthesias warrant monitoring, they aren't presented as acute or life-threatening, indicating low immediate stakes.


Medical Specialty: Orthopedic
Sample Name: Elbow Manipulation

PREOPERATIVE DIAGNOSIS:,  Left elbow with retained hardware.,POSTOPERATIVE DIAGNOSIS: , Left elbow with retained hardware.,PROCEDURE: , ,1.  Left elbow manipulation.,2.  Hardware removal of left elbow.,ANESTHESIA:  ,Surgery was performed under general anesthesia.,COMPLICATIONS:,  There were no intraoperative complications.,DRAINS: , None.,SPECIMENS: , None.,INTRAOPERATIVE FINDING: , Preoperatively, the patient is 40 to 100 degrees range of motion with limited supination and pronation of about 20 degrees.  We increased his extension and flexion to about 20 to 120 degrees and the pronation and supination to about 40 degrees.,LOCAL ANESTHETIC:  ,10 mL of 0.25% Marcaine.,HISTORY AND PHYSICAL: , The patient is a 10-year-old right-hand dominant male, who threw himself off a quad on 10/10/2007.  The patient underwent open reduction and internal fixation of his left elbow fracture dislocation.  The patient also sustained a nondisplaced right glenoid neck fracture.  The patient's fracture has healed without incident, although he had significant postoperative stiffness for which he is undergoing physical therapy, as well as use of a Dynasplint.  The patient is neurologically intact distally.  Given the fact that his fracture has healed, surgery was recommended for hardware removal to decrease his irritation with elbow extension from the hardware.  Risks and benefits of the surgery were discussed.  The risks of surgery included the risk of anesthesia, infection, bleeding, changes in sensation and motion of the extremities, failure to remove hardware, failure to relieve pain, continued postoperative stiffness.  All questions were answered and the parents agreed to the above plan.,PROCEDURE:  ,The patient was taken to the operating room and placed supine on the operating table.  General anesthesia was then administered.  The patient's left upper extremity was then prepped and draped in a standard surgical fashion.  Using fluoroscopy, the patient's K-wire was located.  An incision was made over his previous scar.  A subcutaneous dissection then took place in the plane between the subcutaneous fat and muscles.  The K-wires were easily palpable.  A small incision was made into the triceps, which allowed for visualization of the two pins, which were removed without incident.  The wound was then irrigated.  The triceps split was now closed using #2-0 Vicryl.  The subcutaneous tissue was also closed using #2-0 Vicryl and the skin with #4-0 Monocryl.  The wound was clean and dry and dressed with Steri-Strips, Xeroform, and 4 x 4s, as well as bias.  A total of 10 mL of 0.25% Marcaine was injected into the incision, as well as the joint line.  At the beginning of the case, prior to removal of the hardware, the arm was taken through some strenuous manipulations with improvement of his extension to 20 degrees, flexion to 130 degrees and pronation supination to about 40 degrees.,DIAGNOSTIC IMPRESSION:  ,The postoperative films demonstrated no fracture, no retained hardware.  The patient tolerated the procedure well and was subsequently taken to the recovery room in stable condition.,POSTOPERATIVE PLAN: , The patient will restart physical therapy and Dynasplint in 3 days.  The patient is to follow up in 1 week's time for a wound check.  The patient was given Tylenol No.  3 for pain.
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DESCRIPTION: Left elbow manipulation and hardware removal of left elbow.

orthopedic, k-wires, dynasplint, elbow manipulation, hardware removal, retained hardware, elbow, hardware,

The situation involves a surgical procedure for removing hardware from the left elbow of a 10-year-old, which is necessary due to irritation and limited movement post-fracture healing. While the procedure itself is common and not life-threatening, it involves general anesthesia and surgical intervention, which carry inherent risks like infection or complications from anesthesia. Additionally, it involves a child, which adds complexity in terms of consent and recovery. The stakes are moderate because while the situation is not life-threatening, it has implications for the child's future mobility and comfort, requiring careful surgical execution and recovery management.


Medical Specialty: Orthopedic
Sample Name: Dupuytren Disease Excision

PREOPERATIVE DIAGNOSIS: , Right hand Dupuytren disease to the little finger.,POSTOPERATIVE DIAGNOSIS:  ,Right hand Dupuytren disease to the little finger.,PROCEDURE PERFORMED:  ,Excision of Dupuytren disease of the right hand extending out to the proximal interphalangeal joint of the little finger.,COMPLICATIONS:  ,None.,BLOOD LOSS: , Minimal.,ANESTHESIA: , Bier block.,INDICATIONS:  ,The patient is a 51-year-old male with left Dupuytren disease, which is causing contractions both at the metacarpophalangeal and the PIP joint as well as significant discomfort.,DESCRIPTION OF PROCEDURE:  ,The patient was taken to the operating room, laid supine, administered a bier block, and prepped and draped in the sterile fashion.  A zig-zag incision was made down the palmar surface of the little finger and under the palm up to the mid palm region.  Skin flaps were elevated carefully, dissecting Dupuytren contracture off the undersurface of the flaps.  Both neurovascular bundles were identified proximally in the hand and the Dupuytren disease fibrous band was divided proximally, which essentially returned to normal-appearing tissue.  The neurovascular bundles were then dissected distally resecting everything medial to the 2 neurovascular bundles and above the flexor tendon sheath all the way out to the PIP joint of the finger where the Dupuytren disease stopped.  The wound was irrigated.  The neurovascular bundles rechecked with no evidence of any injury and the neurovascular bundles were not significantly involved in the Dupuytren disease.  The incisions were closed with 5-0 nylon interrupted sutures.,The patient tolerated the procedure well and was taken to the PACU in good condition.
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DESCRIPTION: Excision of Dupuytren disease of the right hand extending out to the proximal interphalangeal joint of the little finger.  The patient is a 51-year-old male with left Dupuytren disease, which is causing contractions both at the metacarpophalangeal and the PIP joint as well as significant discomfort.

orthopedic, excision of dupuytren disease, proximal interphalangeal joint, dupuytren disease, bier block, pip joint, disease, dupuytren, contractions, metacarpophalangeal, neurovascular, bundles, interphalangeal, finger

Dupuytren's disease excision in orthopedics is a routine surgical procedure aimed at alleviating hand contractures caused by tissue thickening. While surgery always involves some risk, the procedure described seems straightforward with minimal complications, low blood loss, and was tolerated well by the patient. The stakes are not extremely high as the condition is not life-threatening, and the surgery is fairly common in orthopedic practice.


Medical Specialty: Orthopedic
Sample Name: Discharge Summary - ATV Accident

ADMITTING DIAGNOSIS: , Trauma/ATV accident resulting in left open humerus fracture.,DISCHARGE DIAGNOSIS:,  Trauma/ATV accident resulting in left open humerus fracture.,SECONDARY DIAGNOSIS:,  None.,HISTORY OF PRESENT ILLNESS: , For complete details, please see dictated history and physical by Dr. X dated July 23, 2008.  Briefly, the patient is a 10-year-old male who presented to the Hospital Emergency Department following an ATV accident.  He was an unhelmeted passenger on ATV when the driver lost control and the ATV rolled over throwing the passenger and the driver approximately 5 to 10 meters.  The patient denies any loss of consciousness.  He was not amnestic to the event.  He was taken by family members to the Iredell County Hospital, where he was initially evaluated.  Due to the extent of his injuries, he was immediately transferred to Hospital Emergency Department for further evaluation.,HOSPITAL COURSE: , Upon arrival in the Hospital Emergency Department, he was noted to have an open left humerus fracture.  No other apparent injuries.  This was confirmed with radiographic imaging showing that the chest and pelvis x-rays were negative for any acute injury and that the cervical spine x-ray was negative for fracture malalignment.  The left upper extremity x-ray did demonstrate an open left distal humerus fracture.  The orthopedic surgery team was then consulted and upon their evaluation, the patient was taken emergently to the operating room for surgical repair of his left humerus fracture.  In the operating room, the patient was prepared for an irrigation and debridement of what was determined to be an open type 3 subcondylar left distal humerus fracture.  In the operating room, his upper extremity was evaluated for neurovascular status and great care was taken to preserve these structures.  Throughout the duration of the procedure, the patient had a palpable distal radial pulse.  The orthopedic team then completed an open reduction and internal fixation of the left supracondylar humerus fracture.  A wound VAC was then placed over the wound at the conclusion of the procedure.  The patient tolerated this procedure well and was returned to the Pediatric Intensive Care Unit for postsurgical followup and monitoring.  His diet was advanced and his pain was controlled with pain medication.  The day following his surgery, the patient was evaluated for a potential for closed head injury given the nature of his accident and the fact that he was not wearing a helmet during his accident.  A CT of the brain without contrast showed no acute intracranial abnormalities moreover his cervical spine was radiographically and clinically cleared and his C-collar was removed at that point.  Once his C spine had been cleared and the absence of a closed head injury was confirmed.  The patient was then transferred from the Intensive Care Unit to the General Floor bed.  His clinical status continued to improve and on July 26, 2008, he was taken back to the operating room for removal of the wound VAC and closure of his left upper extremity wound.  He again tolerated this procedure well on his return to the General Pediatrics Floor.  Throughout his stay, there was concern for compartment syndrome due to the nature and extent of his injuries.  However, frequent checks of his distal pulses indicated that he had strong peripheral pulses in the left upper extremity.  Moreover, the patient had no complaints of paresthesia.  There was no demonstration of pallor or pain on passive motion.  There was good capillary refill to the digits of the left hand.  By the date of the discharge, the patient was on a full pediatric select diet and was tolerating this well.  He had no abdominal tenderness and there were no abdominal injuries on exam or radiographic studies.  He was afebrile and his vital signs were stable and once cleared by Orthopedics, he was deemed appropriate for discharge.,PROCEDURES DURING THIS HOSPITALIZATION:,1.  Irrigation and debridement of open type 3 subcondylar left distal humerus fracture (July 23, 2008).,2.  Open reduction and internal fixation of the left supracondylar humerus fracture (July 23, 2008).,3.  Negative pressure wound dressing (July 23, 2008).,4.  Irrigation and debridement of left elbow fracture (July 26, 2008).,5.  CT of the brain without contrast (July 24, 2008).,DISPOSITION:  ,Home with parents.,INVASIVE LINES: , None.,DISCHARGE INSTRUCTIONS:  ,The patient was instructed that he can return home with his regular diet and he was asked not to do any strenuous activities, move furniture, lift heavy objects, or use his left upper extremity.  He was asked to followup with return appointment in one week to see Dr. Y in Orthopedics.  Additionally, he was told to call his pediatrician, if he develops any fevers, pain, loss of sensation, loss of pulse, or discoloration of his fingers, or paleness to his hand.
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DESCRIPTION: Trauma/ATV accident resulting in left open humerus fracture.

orthopedic, humerus fracture, trauma, irrigation and debridement, atv accident, upper extremity, humerus, fracture,

This situation involves a 10-year-old patient who suffered a significant injury from an ATV accident, resulting in an open humerus fracture. The case required surgical intervention and close monitoring to prevent complications like infection and compartment syndrome. While the patient is now stable and discharged with specific follow-up instructions, the initial condition was serious due to the potential for severe complications. However, the current situation is not as high-stakes as it initially was, given the successful surgery and the patient's stable condition upon discharge. The potential issues now mostly relate to monitoring and adhering to discharge instructions to ensure full recovery and prevent complications.


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Medical Specialty: Orthopedic
Sample Name: Decompressive Laminectomy

PREOPERATIVE DIAGNOSIS: , T12 compression fracture with cauda equina syndrome and spinal cord compression.,POSTOPERATIVE DIAGNOSIS:,  T12 compression fracture with cauda equina syndrome and spinal cord compression.,OPERATION PERFORMED: , Decompressive laminectomy at T12 with bilateral facetectomies, decompression of T11 and T12 nerve roots bilaterally with posterolateral fusion supplemented with allograft bone chips and pedicle screws and rods with crosslink Synthes Click'X System using 6.5 mm diameter x 40 mm length T11 screws and L1 screws, 7 mm diameter x 45 mm length.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS:,  400 mL, replaced 2 units of packed cells.,Preoperative hemoglobin was less than 10.,DRAINS:,  None.,COMPLICATIONS:,  None.,DESCRIPTION OF PROCEDURE: , With the patient prepped and draped in a routine fashion in the prone position on laminae support, an x-ray was taken and demonstrated a needle at the T12-L1 interspace.  An incision was made over the posterior spinous process of T10, T11, T12, L1, and L2.  A Weitlaner retractor was placed and cutting Bovie current was used to incise the fascia overlying the dorsal spinous process of T10, T11, T12, L1, and L2.  An additional muscular ligamentous attachment was dissected free bilaterally with cutting Bovie current osteotome and Cobb elevator.  The cerebellar retractors were placed in the wound and obvious deformation of the lamina particularly on the left side at T12 was apparent.  Initially, on the patient's left side, pedicle screws were placed in T11 and L1.  The inferior articular facet was removed at T11 and an awl placed at the proximal location of the pedicle.  Placement confirmed with biplanar coaxial fluoroscopy.  The awl was in appropriate location and using a pedicle finder under fluoroscopic control, the pedicle was probed to the mid portion of the body of T11.  A 40-mm Click'X screw, 6.5 mm diameter with rod holder was then threaded into the T11 vertebral body.,Attention was next turned to the L1 level on the left side and the junction of the transverse processes with the superior articular facet and intra-articular process was located using an AM-8 dissecting tool, AM attachment to the Midas Rex instrumentation.  The area was decorticated, an awl was placed, and under fluoroscopic biplanar imaging noted to be at the pedicle in L1.  Using a pedicle probe, the pedicle was then probed to the mid body of L1 and a 7-mm diameter 45-mm in length Click'X Synthes screw with rod holder was placed in the L1 vertebral body.,At this point, an elongated rod was placed on the left side for purposes of distraction should it be felt necessary in view of the MRI findings of significant compression on the patient's ventral canal on the right side.  Attention was next turned to the right side and it should be noted that the dissection above was carried out with operating room microscope and at this point, the intraspinous process ligament superior to the posterior spinous process at T12 was noted be completely disrupted on a traumatic basis.  The anteroposterior spinous process ligament superior to the T12 was incised with cutting Bovie current and the posterior spinous process at T12 removed with a Leksell rongeur.  It was necessary to remove portion of the posterior spinous process at T11 for a full visualization of the involved laminar fractures at T12.,At this point, a laminectomy was performed using 45-degree Kerrison rongeur, both 2 mm and 4 mm, and Leksell rongeur.  There was an epidural hematoma encountered to the midline and left side at the mid portion of the T12 laminectomy and this was extending superiorly to the T11-T12 interlaminar space.  Additionally, there was marked instability of the facets bilaterally at T12 and L1.  These facets were removed with 45-degree Kerrison rongeur and Leksell rongeur.  Bony compression both superiorly and laterally from fractured bony elements was removed with 45-degree Kerrison rongeur until the thecal sac was completely decompressed.  The exiting nerve roots at T11 and T12 were visualized and followed with Frazier dissectors, and these nerve roots were noted to be completely free.  Hemostasis was controlled with bipolar coagulation.,At this point, a Frazier dissector could be passed superiorly, inferiorly, medially, and laterally to the T11-T12 nerve roots bilaterally, and the thecal sac was noted to be decompressed both superiorly and inferiorly, and noted to be quite pulsatile.  A #4 Penfield was then used to probe the floor of the spinal canal, and no significant ventral compression remained on the thecal sac.  Copious antibiotic irrigation was used and at this point on the patient's right side, pedicle screws were placed at T11 and L1 using the technique described for a left-sided pedicle screw placement.  The anatomic landmarks being the transverse process at T11, the inferior articulating facet, and the lateral aspect of the superior articular facet for T11 and at L1, the transverse process, the junction of the intra-articular process and the facet joint.,With the screws placed on the left side, the elongated rod was removed from the patient's right side along with the locking caps, which had been placed.  It was felt that distraction was not necessary.  A 75-mm rod could be placed on the patient's left side with reattachment of the locking screw heads with the rod cap locker in place; however, it was necessary to cut a longer rod for the patient's right side with the screws slightly greater distance apart ultimately settling on a 90-mm rod.  The locking caps were placed on the right side and after all 4 locking caps were placed, the locking cap screws were tied to the cold weld.  Fluoroscopic examination demonstrated no evidence of asymmetry at the intervertebral space at T11-T12 or T12-L1 with excellent positioning of the rods and screws.  A crosslink approximately 60 mm in width was then placed between the right and left rods, and all 4 screws were tightened.,It should be noted that prior to the placement of the rods, the patient's autologous bone, which had been removed during laminectomy portion of the procedure and cleansed off soft tissue and morcellated was packed in the posterolateral space after decortication had been effected on the transverse processes at T11, T12, and L1 with AM-8 dissecting tool, AM attachment as well as the lateral aspects of the facet joints.  This was done bilaterally prior to placement of the rods.,Following placement of the rods as noted above, allograft bone chips were packed in addition on top of the patient's own allograft in these posterolateral gutters.  Gelfoam was used to cover the thecal sac and at this point, the wound was closed by approximating the deep muscle with 0 Vicryl suture.  The fascia was closed with interrupted 0 Vicryl suture, subcutaneous layer was closed with 2-0 Vicryl suture, subcuticular layer was closed with 2-0 inverted interrupted Vicryl suture, and the skin approximated with staples.  The patient appeared to tolerate the procedure well without complications.
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DESCRIPTION: Decompressive laminectomy at T12 with bilateral facetectomies, decompression of T11 and T12 nerve roots bilaterally with posterolateral fusion supplemented with allograft bone chips and pedicle screws and rods with crosslink Synthes ClickX System.

orthopedic, facetectomies, decompression, posterolateral fusion, synthes click'x system, decompressive laminectomy, leksell rongeur, kerrison rongeur, transverse processes, thecal sac, nerve roots, pedicle screws, spinous process, pedicle, process, screws, rods, laminectomy, decompressive, spinous,

The situation involves a complex surgical procedure, decompressive laminectomy, for a patient with a T12 compression fracture, cauda equina syndrome, and spinal cord compression. These conditions are serious as they can lead to significant complications if not addressed, such as permanent nerve damage, paralysis, or loss of bladder and bowel control. The procedure described is intricate, requiring precision and expertise, involving spinal hardware placement and neurological structures. Complications during or after such surgeries can have severe consequences for the patient's health and quality of life. Thus, this surgical intervention is considered high-stakes.


Medical Specialty: Orthopedic
Sample Name: Diagnostic Arthroscopy

PREOPERATIVE DIAGNOSIS:,  Torn rotator cuff, right shoulder.,POSTOPERATIVE DIAGNOSES:,1.  Torn rotator cuff, right shoulder.,2.  Subacromial spur with impingement syndrome, right shoulder.,PROCEDURE PERFORMED:,1.  Diagnostic arthroscopy with subacromial decompression.,2.  Open repair of rotator cuff using three Panalok suture anchors.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:  ,Approximately 200 cc.,INTRAOPERATIVE FINDINGS: , There was noted to be a full thickness tear to the supraspinatus tendon at the insertion of the greater tuberosity.  There is moderate amount of synovitis noted throughout the glenohumeral joint.  There is a small subacromial spur noted on the very anterolateral border of the acromion.,HISTORY: , This is a 62-year-old female who previously underwent a repair of rotator cuff.  She continued to have pain within the shoulder.  She had a repeat MRI performed, which confirmed the clinical diagnosis of re-tear of the rotator cuff.  She wished to proceed with a repair.  All risks and benefits of the surgery were discussed with her at length.  She was in agreement with the above treatment plan.,PROCEDURE: , On 08/21/03, she was taken to the Operative Room at ABCD General Hospital.  She was placed supine on the operating table.  General anesthesia was applied by the Anesthesiology Department.  She was placed in the modified beachchair position.  Her upper extremity was sterilely prepped and draped in usual fashion.  A stab incision was made in the posterior aspect of the glenohumeral joint.  A camera was placed in the joint and was insufflated with saline solution.  Intraoperative pictures were obtained and the above findings were noted.  A second port site was initiated anteriorly.  Through this a probe was placed and the intraarticular structures were palpated and found to be intact.  A tear of the inner surface of the rotator cuff was identified.  The camera was then taken to the subacromial space.  A straight lateral portal was also used and a shaver was placed into the subacromial space.  Further debridement of the anterolateral border of the acromion was performed to remove evidence of the subacromial spur, which had reformed.  The edges of the rotator cuff were then debrided.  The camera was then removed and the shoulder was suction and dried.  A lateral incision was made over the anterolateral border of the acromion.  Subcuticular tissues were carefully dissected.  Hemostasis was controlled with electrocautery.  The deltoid musculature was then incised and aligned with its fibers exposing the rotator cuff tear and the edges were further debrided using a rongeur.  A trough was then made in the greater tuberosity using the rongeur.  Two Panalok anchors were then placed within the trough and weaved through the suture and third Panalok anchor was placed medial to the trough and weaved through the rotator cuff.  The ends of the suture were tied down from the fixating the rotator cuff within the trough.  The rotator cuff was then further oversewed using the Panalok suture.  The wound was then copiously irrigated and it was then suction dried.  The deltoid muscle was reapproximated using #1 Vicryl.  A continuous infusion pump catheter was placed into the subacromial space to help with postoperative pain control.  The subcutaneous tissues were reapproximated with #2-0 Vicryl.  The skin was closed with #4-0 PDS running subcuticular stitch.  Sterile dressing was applied to the upper extremity.  She was then placed in a shoulder immobilizer.  She was transferred to the recovery room in apparent stable and satisfactory condition.  Prognosis for this patient was guarded.  She will begin pendulum exercises postoperative day #3.  She will follow back in the office in 10 to 14 days for reevaluation.  Physical therapy initiated approximately six weeks postoperatively.
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DESCRIPTION: Torn rotator cuff and subacromial spur with impingement syndrome, right shoulder.  Diagnostic arthroscopy with subacromial decompression and open repair of rotator cuff using three Panalok suture anchors.

orthopedic, subacromial decompression, panalok suture, repair of rotator cuff, torn rotator cuff, diagnostic arthroscopy, subacromial space, subacromial spur, arthroscopy, panalok, shoulder, subacromial,

The situation involves a surgical procedure for a torn rotator cuff, which is a common but significant orthopedic condition. The surgery, while routine for orthopedic specialists, is still invasive and has inherent risks. The patient has already undergone previous surgery for the rotator cuff but continues to experience pain, indicating potential complications or challenges in treatment. The surgery required general anesthesia and involved specific techniques and tools, such as suture anchors, which add complexity. The patient's history and informed consent also emphasize the seriousness of the surgical intervention. However, there were no complications during surgery, and the prognosis is guarded but not immediately critical. Therefore, while the stakes are more than moderate, they are not life-threatening or emergency-level high.


Medical Specialty: Orthopedic
Sample Name: de Quervain Release - Carpal

PREOPERATIVE DIAGNOSIS,1.  Carpal tunnel syndrome.,2. de Quervain's stenosing tenosynovitis.,POSTOPERATIVE DIAGNOSIS,1.  Carpal tunnel syndrome.,2. de Quervain's stenosing tenosynovitis.,TITLE OF PROCEDURE,1.  Carpal tunnel release.,2. de Quervain's release.,ANESTHESIA: , MAC,COMPLICATIONS: , None.,PROCEDURE IN DETAIL:  ,After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion.  The arm was exsanguinated with Esmarch and the tourniquet inflated to 250 mmHg.,A longitudinal incision was made in line with the 4th ray, from Kaplan's cardinal line proximally to 1 cm distal to the volar wrist crease.  The dissection was carried down to the superficial aponeurosis.  The subcutaneous fat was dissected radially from 2-3 mm and the superficial aponeurosis cut on this side to leave a longer ulnar leaf.,The ulnar leaf of the cut superficial aponeurosis was dissected ulnarly, and the distal edge of the transverse carpal ligament was identified with a hemostat.  The hemostat was gently placed under the transverse carpal ligament to protect the contents of the carpal tunnel, and the ligament was cut on its ulnar side with a knife directly onto the hemostat.  The antebrachial fascia was cut proximally under direct vision with scissors.,After irrigating the wound with copious amounts of normal saline, the radial leaf of the cut transverse carpal ligament was repaired to the ulnar leaf of the cut superficial aponeurosis with 4-0 Vicryl.  Care was taken to avoid entrapping the motor branch of the median nerve in the suture.  A hemostat was placed under the repair to ensure that the median nerve was not compressed.  The skin was repaired with 5-0 nylon interrupted stitches.,The first dorsal compartment was addressed through a transverse incision at the level of the radial styloid tip.  Dissection was carried down with care taken to avoid and protect the superficial radial nerve branches.  I released the compartment in a separate subsheath for the EPB on the dorsal side.  Both ends of the sheath were released to lengthen them, and then these were repaired with 4-0 Vicryl.  It was checked to make sure that there was significant room remaining for the tendons.  This was done to prevent postoperative subluxation.,I then irrigated and closed the wounds in layers.  Marcaine with epinephrine was placed into all wounds, and dressings and splint were placed.  The patient was sent to the recovery room in good condition, having tolerated the procedure well.
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DESCRIPTION: Carpal tunnel syndrome and de Quervain's stenosing tenosynovitis.  Carpal tunnel release and de Quervain's release.  A longitudinal incision was made in line with the 4th ray, from Kaplan's cardinal line proximally to 1 cm distal to the volar wrist crease.  The dissection was carried down to the superficial aponeurosis.

orthopedic, de quervain's release, carpal tunnel syndrome, tenosynovitis, carpal, incision, aponeurosis, tunnel, cut,

The given procedure involves surgical intervention for carpal tunnel syndrome and de Quervain's stenosing tenosynovitis. While these conditions are common and the surgery is routine in orthopedic practice, it still involves surgical risks, anesthesia, and potential complications. However, the report indicates that the procedure was completed without complications and the patient tolerated it well, suggesting a controlled environment with a low likelihood of severe complications. Thus, while surgical, these procedures are generally not considered highly high-stakes compared to more urgent or life-threatening scenarios.


Medical Specialty: Orthopedic
Sample Name: CT Head and C Spine

CT HEAD WITHOUT CONTRAST AND CT CERVICAL SPINE WITHOUT CONTRAST,REASON FOR EXAM: , Motor vehicle collision.,CT HEAD WITHOUT CONTRAST,TECHNIQUE:,  Noncontrast axial CT images of the head were obtained.,FINDINGS: , There is no acute intracranial hemorrhage, mass effect, midline shift, or extra-axial fluid collection.  The ventricles and cortical sulci are normal in shape and configuration.  The gray/white matter junctions are well preserved.  There is no calvarial fracture.  The visualized paranasal sinuses and mastoid air cells are clear.,IMPRESSION: , Negative for acute intracranial disease.,CT CERVICAL SPINE,TECHNIQUE:  ,Noncontrast axial CT images of the cervical spine were obtained.  Sagittal and coronal images were obtained.,FINDINGS:,  Straightening of the normal cervical lordosis is compatible with patient position versus muscle spasms.  No fracture or subluxation is seen.  Anterior and posterior osteophyte formation is seen at C5-C6.  No abnormal anterior cervical soft tissue swelling is seen.  No spinal compression is noted.  The atlanto-dens interval is normal.  There is a large retention cyst versus polyp within the right maxillary sinus.,IMPRESSION:,1.  Straightening of the normal cervical lordosis compatible with patient positioning versus muscle spasms.,2.  Degenerative disk and joint disease at C5-C6.,3.  Retention cyst versus polyp of the right maxillary sinus.
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DESCRIPTION: Motor vehicle collision.  CT head without contrast and CT cervical spine without contrast.  Noncontrast axial CT images of the head were obtained.

orthopedic, muscle spasms, cervical lordosis, intracranial hemorrhage, motor vehicle collision, axial ct images, ct head, ct, anterior, cyst, polyp, maxillary, contrast, intracranial, sinuses, spine, axial, head, cervical, noncontrast

The situation involves interpreting CT scan results of a patient who suffered a motor vehicle collision. While there are no signs of acute intracranial disease or fractures, there are findings that may suggest muscle spasms and degenerative changes in the cervical spine. While these findings are important and require medical attention, they do not currently indicate immediately life-threatening conditions. However, given the context of motor vehicle collisions, there always remains some level of urgency because of potential undetected injuries. Therefore, the situation is important but not of the highest urgency compared to more acute findings.