Status post scope acromioplasty, rotator cuff repair 08/20/2008.
SUBJECTIVE: The patient notes she is doing well. Is taking
ibuprofen p.r.n. night pain. Wearing her Super Sling as well as
doing Codman's.
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OBJECTIVE:
RIGHT KNEE: Neurovascularly intact. No erythema or ecchymosis
noted. Extension 0, flexion 135. Negative anterior, posterior,
or Lachman's. Negative medial and lateral joint line tenderness.
Negative valgus-varus. Negative McMurray's. +1 crepitus.
Negative Homans. Normal alignment. Negative patellar
apprehension.
LEFT KNEE: No effusion. Extension 0, flexion 135. Negative
anterior, posterior, or Lachman's. Negative medial and lateral
joint line tenderness. Negative valgus, varus. Negative
McMurray's. +1 patellofemoral crepitus. Negative Homans.
Normal alignment. Negative patellar apprehension.
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CURRENT MEDICATIONS/SUPPLEMENTS: Positive for Vicodin and
ibuprofen.
Arthrex
ASSESSMENT: Bilateral knee recurrent patellar instability with
recent increase in left knee symptoms.
PLAN: Options surgical and nonsurgical were discussed
extensively with the patient and her parents. At this time,
patient notes she would like to proceed with nonsurgical
treatment. Prescription for physical therapy was given to the
patient. Was also instructed on home and gym strengthening
exercises as well as modifications, avoiding deep squats. Also
given bilateral U-shaped patellar sleeve. Will follow up with us
if she has increasing, worsening symptoms or failure to improve.
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ASSESSMENT:
1. Right shoulder levator scapulae syndrome.
2. Right elbow lateral epicondylitis.
PLAN: Options and diagnoses were discussed. At this time,
patient notes she would like to proceed with physical therapy as
well as a trigger point injection for her right shoulder. After
sterile preparation, was injected with 1 cc Kenalog mixed with 1
percent lidocaine. After the injection, patient notes positive
improvement. Specific instructions were given to the patient.
The patient also notes she would like to proceed with lateral
epicondyle injection number two. After sterile preparation, the
patient was injected into the right upper lateral epicondyle
space with 0.5 cc Kenalog with 1 percent lidocaine. After the
injection, the patient notes positive improvement. Was
instructed on backing down on activities the next five days, then
proceeding with rehabilitation. Follow up with us in one month,
sooner if any problems.
***************************************************************
SUBJECTIVE:
LEFT KNEE: Neurovascularly intact. No erythema or ecchymosis
noted. No effusion. Extension 0, flexion 135. Negative
anterior, posterior, or Lachman's. Negative medial joint line
tenderness, 1+ lateral joint line tenderness. Negative to valgus
or varus. Negative McMurray's. Trace crepitus. Negative
Homans. Normal alignment.
RIGHT KNEE: Extension 0, flexion 135. Negative anterior,
posterior, or Lachman's. Normal medial or lateral joint line
tenderness. Negative valgus, varus. Negative McMurray's. No
crepitus. Negative Homans.
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was seen in conjunction with Dr. King 06/19/2008. Comes in today
regarding her right knee status post scope ACL reconstruction
with allograft 03/05/2008.
SUBJECTIVE: The patient notes she has had some cracking for the
last three weeks. Not taking any medication. Notes she has been
running, hiking, biking. Seeing physical therapy once a week.
Notes she is still having some swelling. Notes no other
problems.
OBJECTIVE: Right knee neurovascularly intact. No erythema or
ecchymosis noted. Incision is healed. No quad atrophy is noted.
Trace effusion. Hyperextension 2 degrees, flexion 130. Negative
anterior, posterior, Lachman's. Negative medial joint line
tenderness. Negative crepitus. Negative Homans.
ASSESSMENT: Right knee status post ACL reconstruction with
allograft with no obvious postop complications.
PLAN: Postoperative course was discussed.
up with us in six weeks.
Patient will follow
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was seen in conjunction with Dr. King 06/05/2008. He comes in
today regarding his left knee. Status post scope partial medial
meniscectomy, partial lateral medial meniscectomy, chondroplasty
05/21/2008.
SUBJECTIVE: The patient notes he is dong well. Still having
some medial pain with stairs. He has been doing home exercise,
stationary bike and straight leg raises.
OBJECTIVE: Left knee neurovascularly intact. No erythema or
ecchymosis noted. Incision clean, dry, and intact. Extension 0,
flexion 130. No effusion. Negative Homans.
ASSESSMENT: Left knee status post scope with no obvious postop
complications.
PLAN: Postoperative course was discussed. Patient instructed on
continuation of strengthening exercises. Exercises were
discussed as well as instructions were given to the patient.
Will follow up with us on an as needed basis.
************************************************************
Patient denies high blood pressure, heart disease, heart murmur,
irregular heartbeat, diabetes, seizures, any breathing or
bleeding abnormalities, acid reflux, or ulcer.
Fought: IMPRESSION: Five months status post instrumented fusion from L2 to the
sacrum.
was seen in conjunction with Dr. King 10/09/07. Comes in regarding her left shoulder
status post excision lipoma 10/03/2007.
SUBJECTIVE: The patient notes she is not having any problems.
OBJECTIVE: Left shoulder incision clean, dry, intact. Healing. Trace ecchymosis.
ASSESSMENT: Left arm status post lipoma excision with no obvious postop
complications.
PLAN: Postoperative course was discussed. She will follow up with us on an as needed
basis. Knows she can call with questions or concerns.
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was seen in conjunction with Dr. King 10/11/07. He is a new patient;
37-year-old male, height 5 feet 6 inches, weight 160 pounds (occupation: Contractor),
who is right hand dominant.
Patient comes in today regarding his left shoulder. Notes he is having left shoulder
periscapular pain that increases with work activities. One week ago, patient had a
cortisone injection, subacromial space, which did not help him. Patient notes he has had
chronic left shoulder symptoms, possibly from a bicycle accident back 1998.
SPORTS ACTIVITIES/HOBBIES: Patient enjoys jogging, cross-training, and kayaking.
PAST MEDICAL HISTORY: Patient denies high blood pressure, heart disease, heart
murmur, irregular heartbeat, diabetes, seizure, any breathing or bleeding abnormalities,
acid reflux or ulcer.
CURRENT MEDICATIONS: Problem list positive for ibuprofen 800 mg t.i.d.
Cortisone injection one week ago.
SURGICAL HISTORY: Negative.
Patient has no known drug allergies.
TOBACCO USE: None.
ALCOHOL USE: Positive for 1-2 drinks a day.
Otherwise, 13-point review of systems positive for some sleep disturbances.
OBJECTIVE: Left shoulder neurovascularly intact. No erythema or ecchymosis noted.
Forward elevation 180. Internal rotation 110. External rotation is 90-100. Left shoulder
strength 5 on a scale of 5. Trace Neer. Negative Hawkins. Negative apprehension.
Negative O'Brien's. Negative lift off.
ASSESSMENT: Left shoulder/neck levator scapular syndrome with subscapularis
bursitis.
PLAN: Patient was instructed on rehabilitation. Stretching and strengthening was
discussed. Brochures, instructions were given to the patient. He will follow up with us if
he has problems. Knows he can call with questions, all concerns.
*******************************************************************
Patient comes in today regarding his right and left knees. He is
status post bilateral knee arthroscopy, right knee partial medial
meniscectomy, debridement. Left knee status post chondroplasty
05/16/2008.
SUBJECTIVE: The patient notes his right knee is doing very well.
His left knee has some occasional medial sharp pains. Notes no
swelling, feelings of catching. Patient notes he recently has
been moving, so has been busy and has not done extensive physical
therapy.
The patient is scheduled for a right knee diagnostic and
operative arthroscopy, medial meniscus reconstruction with open
wedge tibial valgus osteotomy with internal fixation allograft
bone grafting on 06/20/2008. Patient has questions regarding the
surgery.
OBJECTIVE:
RIGHT KNEE: Neurovascularly intact. No erythema or ecchymosis
noted. Incisions well healed. Extension 0, flexion 130.
Negative Homans.
LEFT KNEE: Extension 0, flexion 130. +1 medial joint line
tenderness. No effusion.
ASSESSMENT:
1. Right knee status post arthroscopy partial medial
meniscectomy with no obvious postop complications, with noted
subtotal medial meniscus genu varum.
2. Left knee status post arthroscopy chondroplasty. He has no
obvious postop complications.
PLAN: Postoperative course was discussed. Activity was
discussed. Patient notes he would like to receive the right knee
diagnostic and operative arthroscopy, medial meniscus
reconstruction, open wedge tibial valgus osteotomy with internal
fixation allograft bone grafting. Extensive discussion was
undertaken with the patient discussing surgery and postoperative
course. Activity: Activity modifications were discussed,
prescriptions, and ***.
Paperwork was given to the patient. He will follow up with us at
the Surgery Center. Knows he can call with questions or
concerns.
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was seen in conjunction with Dr. King 06/30/2008. Comes in today
regarding her right shoulder status post scope partial rotator
cuff repair, acromioplasty 06/27/2008.
SUBJECTIVE: She notes she is doing well; is having moderate
pain, but does not require any pain medications. Wearing her
light sling. Notes no other problems.
OBJECTIVE: Right shoulder neurovascularly intact. No erythema
or ecchymosis noted. Incision clean, dry, and intact.
ASSESSMENT: Right shoulder status post scope acromioplasty,
partial rotator cuff repair with no obvious postop complications.
PLAN: Postoperative course was discussed. Patient instructed on
continuation of the light sling, pain-free range of motion,
Codman. Will follow up with us in three weeks.
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OBJECTIVE:
LEFT SHOULDER: Is neurovascularly intact. No erythema or
ecchymosis noted. Forward elevation of 170, internal rotation
110, external rotation at 90 with 90. Left shoulder strength 5out of 5, with pain. External rotation 5- out of 5, with pain.
+1 Neer. +2 Hawkins.
RIGHT SHOULDER: Full range of motion. Strength 5 out of 5.
Left shoulder MRI was reviewed with the patient. MRI of the
shoulder shows severe supraspinatus, mild infraspinatus, and
scapularis tendinosis. No visible rotator cuff tear.
ASSESSMENT: Left shoulder impingement syndrome with possible
rotator cuff tear.
PLAN: Options and diagnoses were discussed. Brochures and
instructions were given to the patient. She feels she would
prefer to treat with exercise, but hold on the cortisone
injection. Prescription for physical therapy was given to the
patient. She is leaving tomorrow for Croatia; feels she can do
rehab over there. Was also given a shoulder kit. Exercises were
demonstrated. Will follow up with us in two months' time upon
return.