PREOPERATIVE DIAGNOSIS:

Bilateral trigger thumbs.

POSTOPERATIVE DIAGNOSIS:

Bilateral trigger thumbs.

OPERATION PERFORMED:

Bilateral trigger thumbs, A1 pulley release.

SURGEON: John Doe, MD

ASSISTANT: None.

ANESTHESIA: Local MAC.

INDICATION FOR OPERATION: The patient is a (XX)-year-old Hispanic female with history of bilateral trigger thumbs for an extended period of time. She had an attempt at steroid injection to treat the triggered thumbs. The patient’s symptoms did not resolve; therefore, recommendation for bilateral trigger thumb release of the A1 pulley was offered to the patient to alleviate her symptoms. Risks, benefits, and alternatives of the surgery were discussed.

Risk including but not limited to scar, infection, bleeding, nerve or vessel injury, persistent triggering and/or recurrence, need for further surgeries were discussed in detail. Questions were answered and consent was obtained prior to the surgery.

DESCRIPTION OF OPERATION: After informed consent was obtained from the patient, he was taken to the operating theater for bilateral trigger thumbs and A1 pulley release. He was transferred from the gurney to the operating table and placed in supine position. IV sedation was administered by the anesthesia staff, and he was monitored throughout the procedure. After the patient was sedated using a half-half mixture of 1% Xylocaine and 0.5% Marcaine with epinephrine, 6 mL of local anesthetic was injected into the left thumb overlying the A1 pulley to provide operative anesthesia. Five mL was injected into the right thumb overlying the A1 pulley as well. The bilateral upper extremities had well-padded tourniquets placed in the forearms. The bilateral upper extremities were then sterilely prepped and draped in usual fashion. Esmarch bandage was used to exsanguinate the right upper extremity and tourniquet was inflated to 250 mmHg prior to incision.

Using a #15 scalpel blade, a transverse incision just distal to the digital palmar crease overlying the A1 pulley was made approximately 1.5 to 2 cm. Incision was made just through the dermis. The subcutaneous tissues were gently dissected in a blunt fashion with Littler dissecting scissors. Ragnell retractors were placed, both radially and ulnarly to protect the neurovascular structures. Under direct visualization, the A1 pulley was identified, and using a #15 blade, a small nick was made in the A1 pulley. There was thickening of this pulley and hourglass appearance to the flexor pollicis longus tendon was noted underneath the pulley.

Using Littler dissecting scissors, the A1 pulley was opened both distally and extended proximally. The left thumb IP joint could then go through the full range of excursion with improved extension of the thumb. Passively palpitating, with full flexion and extension, no significant locking or triggering was identified. The wound was irrigated with copious amount of sterile normal saline. The wound edges were reapproximated with 5-0 nylon suture in interrupted horizontal mattress fashion. The tourniquet was deflated on the right upper extremity at approximately 10 minutes of use. Adequate perfusion to the right hand was noted after tourniquet was deflated, less than 2 seconds capillary refill of all digits.

Next, attention was directed to the left trigger thumb. An Esmarch bandage was used to exsanguinate the left hand and tourniquet was inflated to 250 mmHg prior to incision. A #15 scalpel blade was used to make a transverse incision approximately 1.5 to 2 cm in length just distal to the palmar digital crease on the volar aspect of the thumb. The incision was made shallow just through the dermis. The subcutaneous tissues were dissected bluntly with Littler dissecting scissors. Ragnell retractors were placed ulnarly and radially protecting the neurovascular structures.

The A1 pulley was identified and was opened longitudinally with a nick using a #15 scalpel blade, then extending the incision through the pulley with the Littler dissecting scissors both distally and proximally. Care was taken to protect the oblique ligament in the thumb.

Again, there was thickening of A1 pulley and a slight bulbous appearance to the flexor pollicis longus tendon just proximal to the constricting portion of the pulley. The thumb was able to go through full excursion. Following release with the A1 pulley, there was no triggering or locking of the thumb. The wound was irrigated with copious amounts of sterile normal saline.

The skin was then closed with 5-0 nylon suture in interrupted horizontal mattress fashion. Tourniquet was deflated at approximately 9 minutes of use with adequate perfusion in the left noted with less than 2 seconds capillary refill felt in thumb and other digits. Xeroform was placed over the wounds and sterile 4 x 4 and a Kling was used to dress the area. Dressings were held in place with 2-inch Coban wrapped lightly about the thumb, hand, and wrist.

The patient tolerated the procedure without complications and was returned to the recovery room in stable condition, appearing comfortable.

She had an MRI in the past that showed some sort of synovial cyst that was diagnosed back in December. She states that her pain in her hip has been related to activities. She has pain going up and down stairs but it is just on the outside.

She denies any groin pain. She has a job that requires her to be up on her feet. The pain is worse at night. The patient saw her primary care physician. She was recommended to have an injection for her spine for synovial cyst, but she decided to not pursue this due to the lack of pain in her low back. She points to the outside of her hip, which she says is tender as well.

OBJECTIVE: The patient has point tenderness over the greater trochanter in the right hip. She has pain laterally with flexion of her hip and adduction of the hip. Range of motion of the right hip is about 10 to 20 internal rotation and 30 or 40 degrees external rotation but is symmetric bilaterally. She has 5/5 iliopsoas, quadriceps, hamstrings, gastrocnemius soleus, EHL and AT bilaterally. Sensation is intact to light touch grossly. She has negative Trendelenburg sign. The patient can stand on 1 leg for 5 seconds bilaterally without any weakness. Abduction strength is 5/5, but she does complain of pain on the right hip, on the outside of her hip. She has negative bicycle sign and Trendelenburg sign bilaterally.

IMAGING: Radiographs from December showed good joint space bilaterally, maybe some posterior inferior signs of some early osteoarthritis on the lateral, otherwise unremarkable.

ASSESSMENT: The patient has some trochanteric bursitis of the right hip.

PLAN: Today, we gave an injection with 80 Kenalog with 4 mL of 1% lidocaine. She was explained the risks and benefits. She has had this in the past and understood. We will have her follow up in 3 months. If she is still complaining of symptoms, we have instructed her to do some exercises to strengthen her abductors as well as stretching for iliotibial band.

HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old male who presents to the emergency department today with the above complaint. The patient states that two days ago he was walking. He states that afterwards he experienced pain to the left knee. The pain is mainly over the lateral aspect of the left knee. There was no trauma or injury, did not fall, nor did he twist the left knee that he is aware of. He has not noticed any swelling, redness or bruising. He declines pain to the left hip, left ankle, and phalanges of the left foot. He came to the emergency department with pain to the left knee for further evaluation. He rates his pain as an 8 on a pain scale of 1-10 with 10 being the most severe.

While here in the emergency department, the patient states that he developed pain to his chest. The pain is central in nature, and he describes it as a “heavy” sensation. The pain radiates to the left upper extremity, and he states that his left arm was “numb.” He also notes that he feels short of breath and has had some nausea, no diaphoresis, no vomiting.

PAST MEDICAL HISTORY: The patient has a prior history of sciatica. According to records, he has a prior history of kidney stones, hypertension, hepatitis C and a prior history of polysubstance abuse. He has hypertension as well as chronic back pain. It appears that the patient was hospitalized on MM/DD/YYYY secondary to chest pain. He had Lexiscan stress test without difficulty. EKG components were negative on post-exercise imaging.

PAST SURGICAL HISTORY: The patient states that he had abdominal surgery secondary to trauma. According to records, he had some type of a stab wound, which required exploratory laparoscopy. He has also had hernia repair x2, surgery for kidney stones, and also surgery secondary to testicular torsion.

MEDICATIONS: Neurontin, Motrin, and Xanax.

ALLERGIES: The patient is allergic to codeine.

SOCIAL HISTORY: The patient denies tobacco, ETOH or illicit drug use.

FAMILY HISTORY: The patient states that his father died of an MI at age 54.

REVIEW OF SYSTEMS:
GENERAL: No fever. No change in appetite or energy.
ENT: No congestion, runny nose, ear pain or sore throat.
EYES: No redness, swelling or drainage.
RESPIRATORY: No cough. The patient notes shortness of breath as per HPI.
CARDIOVASCULAR: Chest pain as per HPI. No palpitations.
GASTROINTESTINAL: Nausea, but no vomiting, diarrhea, no abdominal pain.
GENITOURINARY: No dysuria.
NEUROLOGIC: No headache.
MUSCULOSKELETAL: Left knee pain as per HPI.
SKIN: No rashes.
HEMATOLOGY: No history of abnormal bleeding.
ENDOCRINE: No polydipsia or polyuria.
PSYCHIATRIC: The patient denies depression.

PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature is 36.2 tympanic, pulse 104, respirations 18, BP 148/102, O2 sats 99% on room air.
GENERAL: The patient is well developed, nontoxic, in no acute physical distress.
HEENT: Head: Atraumatic. No scalp lesions or masses: Eyes: Pupils are equal and reactive to light. Extraocular movements are intact. There is no conjunctival discharge or erythema. Ears: No erythema or exudate of the external canals. Both TMs are pearly gray with good light reflex. Nose: No mucosal congestion, discharge or lesions. Mouth: Mucous membranes are moist and pink. There is no pharyngeal erythema or exudate. Uvula is midline. Airway is patent.
NECK: Supple without meningismus. There is no cervical lymphadenopathy.
LUNGS: Equal breath sounds bilaterally. Clear to auscultation without crackles, wheezes or retractions.
HEART: Regular rate and rhythm. There are no murmurs, gallops or rubs.
ABDOMEN: Soft, positive bowel sounds. No organomegaly or masses. No CVA tenderness. Abdomen is nontender. No rebound or guarding. No peritoneal signs. No rigidity.
EXTERNAL GENITALIA: Deferred.
SKIN: No rashes, lesions or pigment changes.
CNS: The patient is alert and oriented x3. Cranial nerves II-XII are grossly intact. EXTREMITIES: No obvious joint deformity. No clubbing, cyanosis or edema. Left lower extremity: The patient lies on the exam bed with his left knee flexed secondary to pain. He does elicit pain with extension of the knee or with full flexion. He is point tender over the lateral aspect of the left knee, but there is no overlying erythema, no edema or ecchymosis. He has full range of motion of the left hip, left ankle, and phalanges of the left foot. Pulses are +2 bilaterally. Cap refill is less than 3 seconds. The patient has good strength and good sensation.

EMERGENCY DEPARTMENT TREATMENT AND COURSE: Left knee x-ray was obtained. Four views reviewed. It was read as no signs of acute fracture, dislocation or marked arthritic changes per radiologist. After coming to the emergency department and going through triage process, the patient developed chest pain. Further diagnostic studies have been ordered. The patient was placed on cardiac monitoring. IV access will be obtained. The patient will receive four baby aspirin p.o., morphine sulfate 4 mg IV, and Zofran 4 mg IV.

CBC, comprehensive metabolic panel, EKG, PT, PTT, urinalysis, cardiac panel at 0 hour and 90 minutes, BNP, ABG, D-dimer, chest x-ray PA and lateral have been ordered. All results are currently pending.

The patient will continue to be monitored. We will obtain all diagnostic results, reassess, and decide on further management/disposition. She has been evaluated and examined by Dr. John Doe, who agrees with this plan.

PREOPERATIVE DIAGNOSIS: Delayed union, anterior process of calcaneus fracture.

POSTOPERATIVE DIAGNOSIS: Delayed union, anterior process of calcaneus fracture, with bone cyst.

PROCEDURES PERFORMED:
1. Removal of delayed union site.
2. Debridement of nonunion.
3. Packing with bone morphogenic protein.

SURGEON: John Doe, MD

ANESTHESIA: Local with monitored anesthesia care.

HEMOSTASIS: Esmarch bandage for approximately 1-1/2 hour.

ESTIMATED BLOOD LOSS: None.

MATERIALS: Were 2-0 and 3-0 Vicryl and 4-0 nylon for closure.

INJECTABLES: Preoperatively 20 mL of 0.5% Marcaine plain, intraoperatively 10 mL of 2% Xylocaine plain, postoperatively 1.5 mL of dexamethasone phosphate plain, and a popliteal block.

DESCRIPTION OF PROCEDURE: The patient was brought to the operating room in the supine position with IV intact for intravenous sedation. She was given 1 gram of Ancef IV piggyback for prophylactic antibiotic. She was transferred from the cart to the operating room table, and after delivering her IV sedation, the preoperative injection was given. She was prepped and draped in the usual and aseptic manner and, after appropriate surgical scrub, the right foot was exsanguinated with a Martin bandage, tourniquet maintaining hemostasis at the right ankle 1 cm proximal to the ankle joint on top of Webril with that same Esmarch bandage.

A curvilinear skin incision was made over the subtalar joint and the calcaneocuboid joint approximately 7 cm in length. This incision was deepened into the superficial tissue, making sure to cauterize any other venous bleeding structures at the site. Neurovascular structure of the intermediate dorsal cutaneous nerve was in the superior skin flap, and the sural nerve was in the inferior skin flap. Both nerves were identified and retracted appropriately. Dissection was carried down through the deep tissue until the level of the extensor digitorum brevis muscle belly. The muscle belly was lifted from its inferior origin on the calcaneus in superior fashion using the Bovie to cauterize as lifting the muscle belly. This allowed for exposure of the anterior process of the calcaneus. A small fracture fragment was noted at the lateral aspect of the calcaneus, which was removed.

Next, the anterior process of the calcaneus was inspected, and a small fracture fragment on the dorsal aspect was removed. The calcaneus surrounding the calcaneocuboid joint was inspected and the bone appeared to be quite soft. There was a deficit seen on the CAT scan, which corresponded specifically with this area, of a possible bone cyst, which may have caused this pathological type of fracture. This bone cyst and fracture line paralleled the calcaneocuboid joint subchondral to the calcaneus articular surface. Fracture fragments, which were removed, were perpendicular to the calcaneal articular surface, which one would see in an inversion injury like the patient had. This possible pathological fracture was filled with decorticated bone, which allowed a Freer elevator to be pushed directly through it. The site was curetted to help the hard cortical and calcaneus bone. The site was flushed and inspected under FluoroScan.

Next, right medical allograft with bone morphogenic protein putty was packed into the delayed union/bone cyst site. It was copiously irrigated once again, and closure was performed with 2-0 Vicryl, closing the muscle belly back to its origin, 3-0 Vicryl to close the subcutaneous tissue, and 4-0 nylon via simple and horizontal interrupted sutures. Betadine-soaked Adaptic as well as a dry sterile dressing were applied after the dexamethasone phosphate injection. Tourniquet was removed. Immediate warmth and perfusion was noted to return to all the digits, one through five, on the right foot. A posterior mold was then formed and applied to the patient with a soft dressing.

The patient had the popliteal block then performed via the anesthesia department, and she was transferred from the operating room table to the cart to the postanesthesia care unit. She is to be admitted for 23-hour observation. She is to be nonweightbearing and given pain medicines p.r.n.

More recently, in the last few weeks, he has had a similar episode of discomfort. Again, he felt another pop in his back. This time, he had a similar episode of low back discomfort. Pain present in the mid low back and spreads up into the mid thoracic region. Recently, the patient was seen by his primary care for this discomfort, about a week ago.

He then states he was lifting another heavy object at his home and felt a similar pull. He then had an episode of about two hours of discomfort where he was unable to move. He was then taken to the emergency room and given IV pain medications and steroids. The emergency room doctor diagnosed him with spasm. The patient says that he had a little bit of tingling in his left great toe at that time. Since Monday, his symptoms have been progressively improving.

He has been using anti-inflammatories, muscle relaxants, and Dilaudid for pain medication as prescribed by the emergency room doctor. He is here today for evaluation. Today, he has a similar low back discomfort. He also has some discomfort above his left iliac crest and some residual soreness in his left hamstring. He has no radiation of pain down the leg.

He has no residual left great toe paresthesias. He has no weakness in the leg. He denies bowel or bladder incontinence. He has not done any of the physical therapy at this time. He continues to take pain medication, mainly anti-inflammatory and muscle relaxant, at night as well as Dilaudid at night for residual discomfort. He has not had any studies for review.

His symptoms are worse again with coughing or bending and twisting and lifting motion. Symptoms seemed to improve with rest.

The patient does have a past medical history of bilateral pulmonary embolism with no known etiology. He is taking Dilaudid 2 mg at night, Zofran 4 mg p.r.n. nausea, ibuprofen 600 mg p.o. t.i.d. diazepam 5 mg p.o. t.i.d. p.r.n. spasm.

Today, he has a similar low back discomfort. He also has some discomfort above his left iliac crest and some residual soreness in his left hamstring. He has no radiation of pain down the leg. He has no residual left great toe paresthesias. He has no weakness in the leg. He denies bowel or bladder incontinence. He has not done any of the physical therapy at this time.

He continues to take pain medication, mainly anti-inflammatory and muscle relaxant, at night as well as Dilaudid at night for residual discomfort. He has not had any studies for review. His symptoms are worse again with coughing or bending and twisting and lifting motion. Symptoms seemed to improve with rest.

The patient does have a past medical history of bilateral pulmonary embolism with no known etiology. He is taking Dilaudid 2 mg at night, Zofran 4 mg p.r.n. nausea, ibuprofen 600 mg p.o. t.i.d. diazepam 5 mg p.o. t.i.d. p.r.n. spasm.

OBJECTIVE: The patient is 6 feet tall and weighs 232 pounds. Blood pressure is 124/90, pulse is 102, respirations are 16. The patient is in no acute distress. He is able to ambulate from sitting to standing position without difficulty. He moves his lower extremities with 5/5 strength with some mild pulling in the low back. Deep tendon reflexes are normoreflexic throughout. He had no beats of clonus present. Sensation is intact in the lower extremities bilaterally.

ASSESSMENT AND PLAN: The patient is a (XX)-year-old male with history of acute low back pain, which is likely lower lumbar musculoskeletal strain with associated spasm. We do agree with primary care physician’s plan and will have the patient start a course of physical therapy at this time. We have given him a new prescription for physical therapy to start, closest to his home.

In addition, we have given him prescription for a new muscle relaxant, Flexeril #50, to start at this time. With regard to Ambien, instructed the patient that if he needs any refills of this medication, that he should go to his primary care physician. Also instructed him to increase his dose of anti-inflammatory medications from 600 to 800 mg three times a day with food. He should use local measures as well, including heat and ice to the back.

We have instructed him to call if there are any changes in his condition, including lower extremity radiation, paresthesias or weakness, and we have instructed the patient to call us with any concerning symptoms. If there are any questions or concerns, Neurosurgery should be contacted.

SUBJECTIVE:  The patient is seen in followup for his left knee and left hip. He has had a left hip femoral neck fracture. He has had progressive osteoarthritic changes. He is having primarily pain in his left hip. It is diffuse pain over the lateral aspect of buttock and groin. His knee has rather diffuse pain as well. No mechanical symptoms there. We had done a knee scope on him several years ago.

OBJECTIVE:  His exam today shows him walking without any ambulatory aid. He has got a cane at home, but he is reticent to use it. He has significantly diminished hip motion, in rotation especially, compared to the right. He can flex up to about 100 degrees. He can get full extension. His knee has really no effusion. He has got no joint line pain today. Zero to 130 of motion. Really no flexion pain. Collaterals are intact. He is neurovascularly intact distally.

X-rays obtained today of the hip and the knee show significant CPPD in the knee, really unchanged. His hip films show complete loss of superior joint space. The hardware is unchanged in position. No evidence of any loosening.

ASSESSMENT AND PLAN:  Left hip osteoarthritis. We think the hip is likely the source of the knee as well given his exam today. We had a long discussion with the patient and his wife about this. He has had a previous corticosteroid injection in the hip, which helped. We talked about treatment options. We recommended total hip arthroplasty to him. We are going to have him see Dr. John Doe. He is very concerned about possibility of that surgery. We answered all their questions as best as we could.

ORTHOPEDIC SOAP NOTE SAMPLE 2

DIAGNOSIS:  Status post Akin osteotomy and distal interphalangeal arthroplasty, left second and third toe.

SUBJECTIVE:  The patient is doing very well at this time. She has very little pain or discomfort. The overall alignment remains excellent; this is both radiographically and clinically.

PLAN:  She will continue to use the toe spacers for another month. Follow up with us in four weeks with repeat x-rays of the left foot and, hopefully, we can release her to other suitable activities at that time if all looks well.

ORTHOPEDIC SOAP NOTE SAMPLE 3

SUBJECTIVE:  The patient and his wife return today. He has had a total knee replacement done on MM/DD/YYYY. He is doing fairly well. He is in rehabilitation. His range of motion with a CPM is from 0 to about 68. He is having some swelling, but he is improving. There is no significant calf tenderness. The patient was seen and examined. He has TED stockings. The incision is clean and dry. Staples are removed. Steri-Strips are placed.

ASSESSMENT AND PLAN:
1.  The patient will get antibiotic sent to his home pharmacy.
2.  He will return in two to four weeks’ time for re-examination. He will call the office in the interim if he has any change in symptoms or any questions.
3.  He will stop his Coumadin and take Ecotrin b.i.d.

ORTHOPEDIC SOAP NOTE SAMPLE 4

SUBJECTIVE:  The patient is doing well. He is about three months status post arthroscopies, partial synovectomy, and medial meniscectomy. He still has some mild swelling, though he is making progress. His range of motion is significantly improved. He still has some low quad weakness, and this is improving with time.

PLAN:  We decided to continue with his home exercise program. We will give him a GenuTrain knee brace, and he will return to see us in two months for repeat examination. Potentially, if he still has some achiness, may consider postoperative cortisone injection.

ORTHOPEDIC SOAP NOTE SAMPLE 5

SUBJECTIVE:  The patient is a (XX)-year-old gentleman, following motor vehicle accident, with abrasions over the right knee and foot. We have been treating him for these abrasions. With pain, he saw (XX) about a week ago for completion of suture removal on his right foot wound. He has been putting some Silvadene on it.

OBJECTIVE:  On examination, the wound is clean, dry, and intact. Dorsiflexion and plantar flexion is full without difficulty. He was able to wear a sneaker yesterday. He is still wearing the walker boot. The knee wound is clean and dry. There is some scabbing over the kneecap. There is no extensive erythema or signs of infection.

ASSESSMENT AND PLAN:  He did have a bout of diarrhea and was seen by the PCP. This seems to be resolving. He seems to be doing quite well. The wound is healing nicely. We will continue with wet-to-dry dressing with Silvadene for the distal wound, and we will see him back in two weeks’ time to make sure he is continuing in the right direction.

ORTHOPEDIC SOAP NOTE SAMPLE 6

SUBJECTIVE:  The patient returns to go over his left Achilles tendon and tendinitis. He has also now developed a right plantar fasciitis that he feels that he got from squatting activities. He found the night splint to be intolerable. He has tried various orthotics, which do not fit into the dress shoes that he wears, and he is interested in what sort of steps could be followed.

OBJECTIVE:  He has fusiform swelling but no significant pain in his left Achilles tendon proximal to its insertion. On the right side, he has medial calcaneal origin tenderness consistent with plantar fasciitis.

ASSESSMENT AND PLAN:  The patient has bilateral Achilles contracture with left Achilles tendinitis and right plantar fasciitis. We are going to send him to physical therapy to get him onto a stretching program, as he has been unsuccessful doing it on his own with a home program. We have gone over usual modalities, recommended arch supports and heel lifts, as well as night splints. He is going try to incorporate these into his daily activities, and we will see him back in six to eight weeks’ time.

PREOPERATIVE DIAGNOSIS: Left hip wound infection.

POSTOPERATIVE DIAGNOSIS: Left hip wound infection.

PROCEDURE PERFORMED: Left hip wound incision and drainage.

SURGEON: John Doe, MD

ASSISTANT: Jane Doe, MD

ANESTHESIA: General.

COMPLICATIONS: None.

ESTIMATED BLOOD LOSS: 250 mL.

INDICATIONS FOR PROCEDURE: This patient is a (XX)-year-old female with a history of total hip arthroplasty on the left side. She was seen and admitted for erythema and copious drainage from her hip wound. She understands the risks, benefits and alternatives of the procedure, including potential for eventual explantation of her hip prosthesis if there is synovial infection.

DESCRIPTION OF PROCEDURE: The patient was correctly identified, and preoperative antibiotics were withheld until cultures could be drawn. She was brought to the operating room and placed supine on the operating room table. After the induction of general endotracheal anesthesia, the patient was propped up into sloppy lateral position using a gel roll under the left buttock. All pressure points were well padded. The left hip was then prepped and draped in the usual sterile fashion.

The patient’s wound was opened along the previous incision site using the 10 blade. Upon entering the subcutaneous fatty layer, there was noted to be large amounts of necrotic fat. There was some purulence noted with this as well. This was removed by the handful. The wound was then preliminarily irrigated using Pulsavac irrigation. The Cobb was then used to scrape the exposed fatty surfaces down to a more healthy-appearing layer. The patient did have significant amount of subcutaneous fat, and her fascial layer was noted to be quite deep in the wound. This was palpated. There was a small rent noted in the deep fascia; however, there was no purulence or drainage expressible from that rent.

The wound was thoroughly irrigated with 9 liters of pulsatile saline lavage, the central three liters of which contained bacitracin. Superficial and deep cultures were sent and 0 Prolene was used to close down the deep fatty layer, and a large Hemovac drain was placed. The skin was then closed with a running 0 Prolene suture. The patient was awoken and was taken to the recovery room in stable condition.

DATE OF CONSULTATION: MM/DD/YYYY

REASON FOR CONSULTATION: Distal radius fracture.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old right-hand dominant male status post fall straight forward onto right outstretched hand, who presents with complaints of pain and deformity about the right wrist.

PAST MEDICAL HISTORY: Significant for migraines.

PAST SURGICAL HISTORY: Significant for undescended testicle repair.

MEDICATIONS: None.

ALLERGIES: No known drug allergies.

SOCIAL HISTORY: The patient lives at home with his grandparents. He is in the (XX)th grade. He denies any tobacco, alcohol or IV drug use.

PHYSICAL EXAMINATION: The patient is afebrile with stable vital signs. He is alert and oriented x3. He is not in any apparent distress. Physical examination of the right upper extremity shows deformity and swelling about the right wrist. There are superficial dorsal abrasions over the wrist with no open wounds or lacerations present. The patient is neurovascularly intact. Motor is intact. Positive FDS, FDP, EDC, IO and FPL. Sensation is intact to light touch in the median, radial, and ulnar distributions, and he has 2+ palpable radial pulse.

IMAGING: Imaging of the right wrist shows a distal radius fracture, which is displaced and volarly angulated. There is also a buckle fracture of the distal ulnar metaphysis.

PROCEDURE: With the patient under conscious sedation, it was closed, reduced, and placed in a cast. Fluoroscopy was used during the closed reduction. Post-reduction films showed improved alignment, but there is still slight volar angulation.

ASSESSMENT: The patient is a (XX)-year-old right-hand dominant male with right distal radius fracture. Now, status post closed reduction, in a cast.

RECOMMENDATIONS: At this time include the following:
1. The patient should elevate his right upper extremity for the next 48 hours.
2. He should be discharged home with proper analgesics per the emergency medicine team.
3. He should keep his cast clean, dry, and intact until followup.
4. He should follow up in clinic this week with Dr. John Doe for future planning. We did discuss with the family that surgical intervention may be necessary if his fracture were to displace further in the cast.

CHIEF COMPLAINT: Left ankle pain.

HISTORY OF PRESENT ILLNESS: The patient is a very pleasant, otherwise healthy (XX)-year-old gentleman who was biking today. He said that he was getting off of his bike. He was stepping on the ball of his foot, when he felt that he hyperflexed his ankle and then he fell down. The patient states that he was wearing his helmet. He did not hit his head. He had no loss of consciousness. He did scrape his left ankle and his left knee, but his only real complaint is pain to his ankle. He states he was unable to bear weight immediately after the event, and here in the emergency room, he is complaining of a 4/10 mild sharp pain to the Achilles tendon of his left ankle, and he denies any other injuries.

PAST MEDICAL HISTORY: None.

ALLERGIES: None.

SOCIAL HISTORY: The patient denies any tobacco, alcohol or drugs. He is very active and bikes regularly.

REVIEW OF SYSTEMS: Musculoskeletal and constitutional as per HPI. Otherwise, 10-point review of systems was done and is negative.

PHYSICAL EXAMINATION:
GENERAL: The patient is well appearing. He is nontoxic. He is alert and oriented x4. GCS 15.
VITAL SIGNS: Blood pressure 126/76, heart rate 70, RR 18, temperature 37.2, and sat 99% on room air.
HEENT: Normocephalic and atraumatic. Pupils are equal, round, and reactive to light. Extraocular muscles are intact without any pain or diplopia. ENT: Tympanic membranes are benign with no hemotympanum. No Battle sign, no raccoon eyes, moist mucous membranes with benign oropharynx.
NECK: Supple. Full range of motion. No midline tenderness to palpation. No stepoff, no deformities.
LUNGS: Clear to auscultation bilaterally.
CHEST WALL: No crepitus. No flail chest. No tenderness to palpation.
HEART: Regular rate and rhythm. No murmurs, rubs or gallops.
ABDOMEN: Soft, nontender, and nondistended.
EXTREMITIES: The bilateral upper extremities and the right lower extremity are basically benign with no bony tenderness and full range of motion, though he has a small abrasion over the left elbow and a small abrasion over the left knee, but compartments are soft. Otherwise, skin is intact. In the left lower extremity, the patient has full range of motion at the hip and at the knee without any pain. He has passive full range of motion in the ankle; however, the patient cannot actively plantarflex, and he has a deficit in the deformity over the left Achilles tendon where he has some pain. DP pulses 2+. Sensation is intact to light touch. Compartments are soft.
NEUROLOGIC: Cranial nerves II through XII are grossly intact. Strength is 5/5 x4 extremities. Sensation is intact to light touch distally.

EMERGENCY DEPARTMENT COURSE: The patient was seen and examined. He had an x-ray done of his ankle. It was interpreted and then confirmed by Radiology. It was a three-view x-ray. There was no evidence of fracture, no evidence of dislocation, no soft tissue swelling. The patient did have a deficit to his Achilles tendon. He was unable to plantarflex, and therefore, it did appear that the Achilles tendon was injured. The patient was placed into a long leg lower extremity splint on the left. See the procedure note below.

PROCEDURE NOTE:  Splint placement: Informed consent was obtained from the patient. All risks and benefits of the procedure were discussed as well as alternatives to care. We applied a long leg posterior splint to the patient’s left lower extremity with the ankle in plantarflexion using an Ace wrap to secure it. The patient was examined both before and after, and he was neurovascularly intact both times. The patient tolerated the procedure well. There were no complications.

MEDICAL DECISION MAKING:  The patient is a very pleasant gentleman who had an injury to his left ankle. The differential diagnosis considered was a fracture, dislocation, or a soft tissue injury, including tendon injuries.

The patient had no evidence of fracture, dislocation; however, it did appear clinically that the patient has an Achilles tendon rupture. The patient was placed into a splint for comfort and immobilization. We discussed the case with the orthopedic service, and they state that the patient could follow up with them this week for likely surgical fixation.

DISPOSITION:  Home.

CONDITION:  Stable.

DIAGNOSIS:  Achilles tendon rupture, left, and splint placement.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female with right much greater than left knee osteoarthritis. She was last evaluated here six months ago, and at that time, she was found to be at arthroplasty-level symptoms with her right knee. A steroid injection was performed in the right knee with good short-term benefits. She has had a return of her arthritis symptoms and continues to desire a total knee replacement.

She has a distant history of conditions both in the right and left knees since childhood, which included patellar dislocations. She never required surgery, instability symptoms resolved in her 20s. She has had symptoms of pain since that time.

The patient had a twisting injury in May last year with increased swelling, which was temporarily relieved with a steroid injection. Her contralateral left knee symptoms are described as mild. Her right knee pain is primarily lateral-sided; however, a good portion is anterior. She takes three to four Vicodin a day for her symptoms. Over the past three years, she had management with steroid injections with decreasing effectiveness.

The patient denies paresthesias. She occasionally uses a cane. Her pain is 8 to 10/10, able to walk about 15 minutes. She describes reactions to some metal jewelry.

The patient has had medical evaluation by her primary care provider as well as cardiology evaluation and has been provided medical clearance to proceed with surgery.

PAST MEDICAL HISTORY: High blood pressure, high cholesterol, and asthma.

PAST SURGICAL HISTORY: Nasal polyps.

MEDICATIONS: Advair, alprazolam, desonide, Vicodin, Nexium 40 mg daily, paroxetine 40 mg daily, pravastatin 20 mg daily, ProAir, valsartan/hydrochlorothiazide 320 mg/25 mg daily, verapamil 240 mg daily, and fexofenadine 180 mg daily.

ALLERGIES: Sulfa.

SOCIAL HISTORY: The patient lives with her significant other. She does not smoke. She drinks once a week.

PHYSICAL EXAMINATION:
VITAL SIGNS: Weight 212 pounds, height 5 feet 5 inches, blood pressure 138/78, and pulse 72.
LUNGS: Clear to auscultation bilaterally.
HEART: Regular rate and rhythm.
ABDOMEN: Soft and nontender with normal bowel sounds.
NEUROLOGIC: Cranial nerves II through XII are intact.
EXTREMITIES: Standing alignment with minimal right-sided valgus deformity, knee with slight flexion contracture. The patient walks with moderate antalgic gait. Range of motion 3 to 90 degrees. There are no surgical scars or incisions, diffuse tenderness medially and laterally, also with patellofemoral compression. Stable ligamentous exam.
NEUROVASCULAR: Exam is intact.

DIAGNOSTIC DATA: X-ray exam, bilateral knee series, demonstrates tricompartmental arthritis laterally, greater than medial. Moderate lateral subluxation of the tibia as well as lateral subluxation of the patella on the sunrise view. MRI of the right knee from last year demonstrating chronic ACL insufficiency with medial and lateral meniscal degenerative tears and tricompartmental osteoarthritis.

ASSESSMENT:
1.  Right much greater than left knee osteoarthritis.
2.  Sensitivity to metal.
3.  Obesity.

PLAN:  We previously discussed options and the patient desires to proceed with right total knee replacement. We will use the Smith & Nephew Oxinium knee to minimize reaction to metal.  The risks, benefits, and alternatives were discussed, including specific risks of loosening of components requiring revision, infection, damage to neurovascular structures, DVT, pulmonary embolism, and anesthetic complications to include death. All of her questions were answered, and informed consent was obtained. The patient will proceed with right total knee arthroplasty with the Smith & Nephew Oxinium knee.