Sample 1
advertisement
Dr. Frank Chen Orthopedics, PAMF Samples <BODY> XXXXX is now 4+ months postop and actually doing quite well. Has occasional discomfort with lifting but otherwise much improved compared to her preoperative status. Happy with progress to date. Been able to sleep on the right side at night. PHYSICAL EXAM: Well-healed incision with excellent range of motion noted. 170 active forward elevation with 60 internal rotation at the side. Negative drop-arm sign noted with 5-/5 cuff strength against resistance. Negative Neer sign. Negative rent test. IMPRESSION: Doing well status post partial right shoulder arthroscopic large rotator cuff repair with SAD/DCR and long head biceps release. PLAN: 1. XXXXX is actually doing quite well especially given the size of the tear. At this point she should continue with her exercise regimen for further strengthening and gradual progressive conditioning of the rotator cuff. 2. She should be careful, however, with regard to heavy overhead lifting which she understands. 3. Follow up in 2 months for final visit. The patient will be cleared for further activities at that point. </BODY> <BODY> XXXXX returns for repeat exam of his knee. He feels better with the brace in place but, unfortunately, still notes discomfort about the anterolateral knee region especially with twisting and pivoting-type motion. He has been able to run but difficulty playing soccer as a result of the twisting-type motion. PHYSICAL EXAM: No swelling or effusion. Full extension, forward flexion to 135. 1+ varus laxity with the end point essentially symmetric. LCL is palpable in figure-4 position with no significant tenderness over the area. He does have residual tenderness from the inferolateral joint line, however. bounce test. Negative DIAGNOSTIC STUDIES: MRI has been re-reviewed and is consistent with LCL sprain. There is an anterior horn tear in the lateral meniscus. IMPRESSION: 1. Left knee LCL sprain with medial femoral condyle contusion, improving clinically. 2. Left knee complex anterior horn lateral meniscal tear, symptomatic. PLAN: 1. At this point XXXXX is doing better with regard to his lateral collateral ligament. It does appear to be stable on exam with an end point and, thus, I do not think this will require surgical intervention. 2. He does have, however, underlying meniscal pathology and this appears to be bothering him especially with twisting and pivoting-type motions. If he chooses to proceed, he would be a candidate for left partial lateral meniscectomy. This will allow him potentially to participate in upcoming soccer season. If he has persistent problems with the LCL down the road, however, this will require open stabilization which will potentially require him to miss the entire season, which he notes he would like to defer that for the time being. He will call back for definitive scheduling. </BODY> <BODY> XXXXX is now six months postop and actually doing very well. He has already completed a couple of triathlons and actually did an ironman swim, after which he noted a fair amount of soreness about the shoulder. Otherwise, doing quite well with increased strength compared to preoperative status. PHYSICAL EXAMINATION: Well-healed incision with full active passive range of motion that is symmetric. No pain with impingement maneuvers, 5/5 rotator cuff strength against with resistance with no significant pain. IMPRESSION: Doing well status post right shoulder arthroscopic cuff repair with SAD and biceps debridement. PLAN: 1. XXXXX is doing very well and he actually has been testing the shoulder out much more than I would have liked. 2. At this point, again he still should be cautious. He may still need work-up and further conditioning and endurance training of the shoulder specifically rotator cuff. 3. Follow up p.r.n. Informed him it would probably take a year to regain 95 percent of all former strength and endurance. However, in the interim, he is already back to all activities as tolerated without restrictions. </BODY> <BODY> XXXXX is now five months postop and doing quite well. She has been cycling quite a bit and would like to do a little hiking. No instability reported, with no pain in the knee. PHYSICAL EXAM: Normal gait pattern with well-healed incisions. Full motion from 0 to 140 flexion, negative Lachman, anterior drawers with firm endpoints but negative pivot-shift. No significant tenderness along the joint line. Mild quads atrophy noted. IMPRESSION: Status post left ACL reconstruction, stable. PLAN: 1. At this point Betty is doing very well and may be cleared to perform all activities as tolerated without restrictions. 2. She should continue to maintain an independent strengthening and conditioning regimen; however, she does have a fair amount of underlying atrophy present. 3. Follow up p.r.n. </BODY> <BODY> XXXXX returns today for review of MRI scan. worsening discomfort since the last visit. PHYSICAL EXAM: He actually notes No interval change. DIAGNOSTIC STUDIES: MRI is consistent with a high-grade partial versus small focal cuff tear of the supraspinatus tendon. Subacromial spurring seen, with moderate AC joint degenerative changes. Bicipital tenosynovitis noted. Possible tear of the anterior superior labrum. IMPRESSION: 1. Right shoulder traumatic rotator cuff high-grade partial versus small focal tear, with underlying AC arthropathy. 2. Right shoulder possible SLAP lesion. PLAN: 1. I have discussed the MRI findings with XXXXX, as well as the treatment options available to him. Certainly, as he does have a fair amount of discomfort with increased limitation at present, he has opted for surgical stabilization. 2. XXXXX is a candidate for a right shoulder arthroscopy with rotator cuff repair and subacromial decompression/distal clavicle resection with labral debridement. The risks and benefits of the procedure were discussed with the patient, who understands and wishes to proceed at this time. 3. In the interim he has been provided some literature on arthroscopy and rotator cuff tears to read. All questions were answered to his satisfaction. </BODY> <BODY> XXXXX is now 7 months postop on the right ankle, and doing much better. She did have posterior tibialis tenosynovitis, which calmed down with anti-inflammatories as well as brief period of immobilization. Minimal discomfort at present. She just has lack of overall strength and endurance. PHYSICAL EXAM: There is some tenderness over the posterior tibialis tendon region. Negative too-many-toes sign. Able to perform a single-limb toe raise, although significant problems with balance and stability noted. No specific tenderness over the Achilles itself with a well healed incision. IMPRESSION: 1. Right ankle posterior tibialis tenosynovitis. 2. Status post right ankle Achilles debridement with primary repair and excision of Haglund deformity. 3. Right ankle anterolateral synovitis, resolved. PLAN: 1. At this point XXXXX's symptoms are much improved, and she just lacks overall conditioning and balance, for which I have recommended a brief course of physical therapy to help in this regard. 2. Otherwise I think with regards to repair, she is clear to perform activities as tolerated. 3. Follow up p.r.n. </BODY> <BODY> XXXXX returns for exam of her knee. She previously had been seen in this office for adhesive capsulitis, which actually resolved. With regard to her right knee, she is noticing increasing discomfort for about the past few months. There is no specific injury, however, that she can recall, although there is still a fair amount of soreness especially with riding, about the lateral knee region. Occasional swelling reported, but no buckling or catching. There is occasional clicking reported. Overall, she thinks her symptoms are getting worse, and unfortunately have not improved with ibuprofen and ice. Dull soreness with occasional sharp pains. PHYSICAL EXAM: Right knee shows no significant swelling or effusions. Full range of motion from 0-135 that is symmetric. Well-maintained patellar mobility. No significant patellofemoral crepitus. There is tenderness at the lateral joint line with discomfort upon McMurray's testing. There is no significant tenderness medially, with no ligamentous laxity otherwise. PAST MEDICAL HISTORY: None. PAST SURGICAL HISTORY: CURRENT MEDICATIONS: ALLERGIES: None. None. No drug allergies. SOCIAL HISTORY: wine per day. Denies tobacco usage. RECREATIONAL ACTIVITIES: cycling. WORK HISTORY: Has one to two glasses of Yoga and cardio exercise, running, A financial analyst. REVIEW OF SYSTEMS: Six-point review of systems is negative. IMPRESSION: 1. Right knee possible lateral meniscal tear. 2. Right shoulder adhesive capsulitis, resolved. PLAN: 1. At this point I do suspect potential meniscal pathology, and given the fact that her symptoms have actually been worsening, with an increase in limitations, I have recommended obtaining an MRI. 2. In the interim she may take antiinflammatory meds symptomatically and she should avoid significant twisting/pivoting as well hyperflexion type activities. 3. Follow up after the MRI. at that time. Further recommendations will follow </BODY> <BODY> XXXXX is now nearly three months postop, actually doing very well. She has been able to walk decently without significant discomfort. Just a little bit of soreness reported in the ankle, but otherwise progressing well with physical therapy. Still working on strengthening and overall stability. PHYSICAL EXAM: Essentially normal gait pattern. Right ankle shows well-healed incisions. No significant tenderness on either side. Approximately 12 degrees of dorsiflexion with 45 plantarflexion. Good inversion/eversion strength against resistance. Able to perform double-limb toe raises. IMAGING STUDIES: X-rays taken today show anatomic reduction with good hardware placement. Syndesmosis well maintained. IMPRESSION: Status post ORIF bimalleolar ankle fracture with syndesmosis fixation, stable. PLAN: 1. At this point XXXXX is doing much better and is healing well and improving clinically. 2. She will benefit from continued PT, as well as further exercise on her own for further strengthening and progressive stabilization/proprioceptive training. 3. She may do low-impact exercises, but do not think it is advisable to do running and jogging at this point, nor playing tennis. 4. Followup in six to eight weeks with x-rays. May be further advanced in activities at that point. </BODY> <BODY> XXXXX is a 58-year-old right-hand-dominant female who has been kindly referred by Dr. Weinrich for evaluation of right knee swelling and pain of nearly one month's duration. There is no injury she can recall and she said she awoke one morning with a fair amount of pain and swelling about the knee. There was a little bit of warmth initially, but overall no erythema or redness. She took a brief course of ibuprofen, which provided a little bit of improvement. However, she still notes a fair amount of soreness and discomfort, especially in the medial lateral aspects of the knee. No significant sharp pains reported, no frank locking or catching. Symptoms appear to be exacerbated by prolonged ambulation, as well as going up and down stairs. She has been wearing a European sleeve. Has applied ice, which has helped a little bit. A fair amount of clicking and popping reported, but no frank locking or catching. PAST MEDICAL HISTORY: 1. Bunion. 2. Depression. 3. Neural hearing loss. 4. Cardiac murmurs. 5. Raynaud syndrome. 6. Esophageal reflux. 7. Chilblains. PAST SURGICAL HISTORY: None reported. CURRENT MEDICATIONS: 1. Ranitidine. 2. Cymbalta. 3. Medroxyprogesterone. 4. Ibuprofen. 5. Carafate. 6. Niaspan. 7. Nortriptyline. ALLERGIES: No drug allergies. SOCIAL HISTORY: Denies tobacco or alcohol use. RECREATIONAL ACTIVITIES: Special Olympics. unspecified. REVIEW OF SYSTEMS: Work history Six-point review of systems is negative. PHYSICAL EXAM: Well-appearing female standing 5'6, weighing 151. Right knee shows trace effusion. Full extension, forward flexion 125, 1 to 2+ patellofemoral crepitus detected. There is tenderness about the lateral joint line with discomfort on McMurray testing. Positive bounce sign. No significant tenderness medially with no neurologic deficits appreciated. DIAGNOSTIC STUDIES: Plain x-rays show mild degenerative changes about the patellofemoral articulation. IMPRESSION: Right knee possible lateral meniscal tear with inflammatory effusion. PLAN: 1. Clinically, I do suspect potential meniscal pathology and, as her symptoms have persisted with marginal improvement, I think it is reasonable to obtain an MRI. 2. In the interim, she may continue to take antiinflammatory meds. I have offered her selective corticosteroid injection at today's visit, which she has declined. 3. Follow up after the MRI. Further recommendations will follow at that time. </BODY>
