€¦ · web viewpatient history. past medical history: hypertension, mitral valve prolapse...

Patient Name DOB: 03/21/YYYY

Patient History

Past Medical History: Hypertension, Mitral Valve Prolapse (MVP), meningitis at 16 years old, contusion from motor cycle accident, head injury, sleep apnea, umbilical hernia, and osteoarthritis.

Surgical History: Right total knee replacement in YYYY, rhinoplasty in YYYY.

Family History: Father had arthritis and cancer, neoplasm of prostate, pacemaker in situ.

Social History: Never smoker. Use alcohol occasionally.

Allergy: No known medication allergy.

Detailed Summary

DATE FACILITY/ PROVIDER

MEDICAL EVENTS PDF REF

Summary of prior-accidental medical records06/11/YYYY Hospital/

ProviderOperative report:

Pre and postoperative diagnosis: Right knee degenerative joint disease.

Operation: Computer-assisted right total knee arthroplasty.

Surgeon: Michael XXXX, MD

Anesthesia: Spinal, David Paul, MD

*Comments: The above visit is not related to subjective injury hence not elaborated.

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Summary of post-accidental medical recordsDate of injury: 07/21/YYYY

07/21/YYYY Hospital/Provider

Accident scene investigation report:

Date of collision: 07/21/YYYYTime: 14:50 hoursNo. of Vehicles: 2Number injured: 1

Vehicle 1:Name: Edward M MartinezStreet: 1 Elder AvCity: FarmingvilleState: NYVehicle year: 2007Make: CHEVVehicle type: PickPlate number: 24007MBState of registration: NY

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Vehicle 2:Name of driver: Peter OrtizStreet: 200 LWR Sheep PAS RDCity or Town: SetauketState: NYVehicle year: YYYYMake: HDVehicle type: MCYPlate number: 62SE52

Place where accident occurred: County: SuffTown of: SmithtownRoad on which accident occurred: Middle Country Road, 425 feet west of Lake Ave

Accident description/officer’s notes: Vehicle 1 operating westbound, Middle Country Road, looking to make a left tum into parking lot of 660 Middle Country Road. Operator states uninvolved vehicles traveling eastbound on Middle Country Road stopped to allow him to make the tum, but vehicle 1 hit vehicle 2, a motorcycle, who was operating eastbound in the shoulder. Vehicle 2 states was operating in the shoulder because traffic was backed up.

Snapshot:


ER triage record:

Chief complaint: Motor vehicle collision

Chief complaint quote/comments: Patient presents status post being hit by truck, reports only Left Lower Extremity (LLE) avulsion and some mid back pain 7 of 10 on pain scale, denies Loss of Consciousness (LOC), states "he rolled", Up-to-Date (UTD) on tetanus.

Initial vital signs @ 1631 hours:Temperature: 98.1o FHeart rate: 90 beats/minuteRespiratory rate: 19 breaths/minute

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SpO2: 97%SpO2 obtained on: Room airNoninvasive (NIV) blood pressure: 152/86 mmHgBMI: 28 kg/m2

Pain numeric at rest pain score: 7-10/10ESI acuity: 4

Arrival information:Mode of arrival: Private vehicleMeans of arrival: WheelchairAccompanied by: SpouseTriage historian: PatientArrival from: Home

Patient safety bands: ID band in place: YesPain medication: Ordered.

Morse scale score: 20Safe program level: Standard risk 0-44

Dysphagia/swallow screen:Current nutrition/hydration: RegularFully alert: YesManages secretions: YesClear voice/strong cough: YesSwallowing difficulty: NoFacial symmetry: Symmetrical

Head to toe assessmentNeuro assessment:Level of consciousness: Alert and awake; follows commandsOrientation: Oriented to person, place and timeNeuro mentation: NormalNeuro behavior: Calm; cooperativeFacial symmetry: SymmetricalNeuro motor mobility left: NormalNeuro motor mobility right: Normal

Integumentary assessment:Skin color: Normal for raceSkin temperature/moisture: WarmPressure ulcers present on admission: NoSkin integrity: WoundsWound type #1: AvulsionWound location #1: ShinWound laterality #1: LeftWound area #1: LowerWound appearance #1: Bleeding minimallyGeneral comments: Patient status post motorcycle accident; positive for

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avulsion noted to LLE (shin); wound is open, exposing flesh/soft tissue; bleeding controlled; no obvious bone exposed.

Disposition: DischargedMode of transport: Ambulatory; with familyDischarge type: HomeCondition on disposition: ImprovedCondition on discharge: StableIV removed: YesInstructed on: Discharge instructions; follow up/referral plansDate/time provided: 07/22/YYYY 00:25 hoursCheck for these symptoms and call or schedule appointment with provider: Fever; pain; drainage; redness; non-healing wound; vomiting.


ED provider note @ 09:12 to 22:20 hours:

Chief complaint: Motor vehicle collision

History of present illness: 47-year-old male presents ED status post motorcycle versus truck MVA 4.5 hours ago. Patient was driving his motorcycle was making a turn when a truck turned into him, reports hitting his left shin on the bumper of the truck and falling to the ground. States the truck was traveling at a slow speed. Patient was wearing a helmet, no head trauma or loss of consciousness. Associated with laceration and pain to his left shin. Also complains of bilateral rib pain. Patient denies headache, change in vision, neck pain, back pain, abdominal pain, shortness of breath, numbness, tingling. Does not take anticoagulants. Tetanus is up-to-date. Patient was ambulatory after the MVA.

Nurses' notes reviewed: The history from nurses' notes was reviewed but my personal history reveals:History discrepancy: No back pain

Review of systems:Musculoskeletal: Positive for painSkin: Positive for laceration

Physical examination:Constitutional: Well-developed, well nourished, in no acute distress. Appears uncomfortable.Head: Normocephalic atraumaticEyes: Pupils equally round and reactive to light, extraocular movements intactENT: Mucous membranes moistNeck: Supple, full range of motion, no vertebral tenderness or bony step-off. Normal alertness, no apparent toxication.Respiratory: Effort normal, no tachypnea or retractions. Breath sounds clear to auscultation bilaterally. No pleuritic chest painChest wall: Moderate tenderness to bilateral lateral ribs and to left anterior ribs 7-9. No crepitus, ecchymosis, or deformity. No flail chest or asymmetrical movementCardiac: Heart regular rate and rhythm, normal S1, S2. No murmurs.

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Abdomen: Soft, nondistended, nontender to palpation in all four quadrants. No guarding or rebound tenderness, no palpable mass. No tenderness to bilateral upper quadrants, no bruising to abdomenBack: Range of motion intact without pain. No vertebral tenderness or bony step off. No paraspinal tendernessMusculoskeletal: Full range of motion all extremities. Tenderness to left medial knee, left shin, and left distal fibula. No crepitus or deformity. Neurovascularly intact distal to injury. 2+ pulses to left dorsalis pedis, capillary refill < 2 secondsNeurological: Alert and oriented x 3, mentation normal. Motor strength 5/5, sensation grossly normal. No numbness or tinglingSkin: Color normal, 6 cm gaping laceration present to left mid shin, about 1.5 cm deep. Muscle visible through wound. No bone visualized. No foreign body or debris. Mild active bleeding.Psychological: Mood calm

Diagnostic studies: EKG, X-ray chest, left knee, ribs, left tibia and fibula reviewed.

*Comments: Direct reports of the diagnostic studies have been included in individual rows below for reference.

Medical decision making:Differential diagnosis: Contusion; fracture; lacerationReason ASA not given: Aspirin is not indicated for this conditionData reviewed: Vital signs; nurses notes; lab test results; radiology test resultsDiscussed clinical and radiological findings with: Patient; familyPain medication: Ordered

ED course: Discussed with patient signs of compartment syndrome (numbness, tingling, pain out of proportion, pulselessness, cold extremity) and advised patient to return to ED immediately if he has any the signs. Patient reevaluated has no signs of compartment syndrome at this time.

Comments: Patient with laceration to lower extremity after MVC.Plan: X-ray and stiches.

ED primary diagnosis: Laceration of lower extremityED additional diagnosis: Contusion of leg, contusion of rib.

Disposition:Disposition: DischargedThe decision to discharge the patient was made on: 21-Jul-YYYY 22:16Discharge type: HomeCondition on disposition: StableED discharge prescriptions: Keflex 500 mg oral capsule. Percocet 5/325 325 mg-5 mg oral tablet.Follow-up: Follow-up with your primary care provider.

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Procedure report 22:13 hours:

Procedure name: Laceration repair

Time out: A procedural timeout was performed prior to the start of procedure to verify that this is the correct patient receiving the correct procedure at the correct site. The patient’s allergies were reviewed.

Procedure date/time: 07/21/YYYY 22:13Laceration number (#): 1Procedure performed by: Leanne Rubin, PALength cm: 6 cmCaused by: Motor Vehicle Accident (MVA)Anatomic location: Left shinType of laceration: Gaping; deepCleansed: Cleansed; copious irrigation; extensive cleaningSite prep: Povidone iodineLocal anesthesia: 1% Lidocaine; with Epinephrine Injury complications: Deep subcutaneous woundWound closure/sutures: Subcutaneous suture; skin sutureSubcutaneous suture: InterruptedSubcutaneous suture type: Plain gut 4.0 - 4 suturesSkin suture: InterruptedSkin suture type: Ethilon 4.0 - 14 suturesNumber of retention sutures: 18

Peripheral neurological evaluation: Intact; nerve function intact; tendon function intact; vascular function intact.

Laceration repair procedure details: The wound was explored to base in bloodless field. No foreign body.

Tolerance: Patient tolerated procedure well.Dressing: 4x4s; KerlixComplications: NoneEstimated blood loss (EBL): NoneWas procedural sedation used? NoDischarge instructions: Discharge instructions given

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Echocardiogram:

Ventricular rate: 77 BPMAtrial rate: 77 BPMP-R interval: 198 msQRS duration: 110 msQ-T interval/ QTC calculation bezet: 368/416 msP-R-T axes: 46-16-17 degrees

Findings: Normal sinus rhythm

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Minimal voltage criteria for Left Ventricular Hypertrophy (LVH), may be normal variant

Borderline ECG When compared with ECG of 05/30/YYYY 08:31 premature ventricular

complexes are no longer present07/21/YYYY Hospital/

ProviderX-ray of chest 2 views and ribs 3 views:

History: Pain after motor vehicle collision

Findings: Lungs are clear. Cardiac and mediastinal contours are normal. No displaced rib fracture.

Impression: No acute cardiopulmonary finding. No displaced rib fracture.

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X-ray of left knee 3 views and left tibia/fibula 2 views:

History: Pain.

Findings: Anatomic alignment. No acute fracture or dislocation. Mild degenerative changes of the knee. There are also degenerative changes of the tibiotalar joint. Ossific fragment adjacent to the distal fibular consistent with sequela of prior avulsion injury. Soft tissues are unremarkable.

Impression: No acute osseous finding.

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ED nursing assistant notes @ 00:31 hours:

General: Comfort care: Repositioned; wait time explained.

Safety measures: Bed in low position, wheels locked; call device/patient care articles within reach; ID band in place; upper side rails raised x2.

High safe (45 or greater Morse scale score): Movable equipment locked prior to transfer, nonskid yellow footwear when out of bed/ambulating, high risk safe sign above bed, high risk safe sign outside of room, yellow wrist band on patient, yellow safe label on patient’s chart, pathways in room are clear/uncluttered and dry, lighting adjusted for task/safety, hourly rounds, safe fall prevention brochure given to patient, discussed safe program with patient/family, patient instructed to ring call bell for assistance, fall risks associated with medication regime review, medication regime reviewed with MD/Pharmacist; side rails raised x 2

Nutrition diet type: Regular

Vital signs @ 21:04 hours:Heart rate: 87 beats/minuteRespiratory rate: 18 breaths/minuteSpO2: 99%SpO2 obtained on: Room airNon-invasive (NIV) blood pressure: 146/82 mmHgPain numeric at rest pain score: 6-9/10

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ER triage record @ 17:21 hours:

Chief complaint: Leg painChief complaint quote/comments: Complains of pain to left calf x 1 week.

Pain numeric at rest: 0/10 no pain.ESI acuity: 3

Arrival information:Mode of arrival: Private vehicleMeans of arrival: AmbulatoryAccompanied by: AloneTriage historian: PatientArrival from: HomePatient safety bands: ID band in place: Yes

Vital signs @ 17:18 hours:Temperature: 98.2o FHeart rate: 70 beats/minuteRespiratory rate: 18 breaths/minuteSpO2: 97%SpO2 obtained on: Room airNon-invasive (NIV) blood pressure: 142/81 mmHgBMI: 29.5 kg/m2

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ED provider note @ 18:41 hours:

History of present illness:Time seen: 07/30/YYYY 18:42 hoursChief complaint: Complains of pain to left calf x 1 weekPresenting symptoms: PainOnset: Days 7Quality: Deep painSeverity: ModerateLocation: LegLaterality: LeftArea: CalfRadiation: No radiationContext: Patient was in a motorcycle accident 8 days ago, he had a laceration to the left shin had a closed any of his presents today for suture removal however complain of calf pain.Significant negative findings: No difficulty bearing weight.

Review of system:Musculoskeletal: Positive for pain, stiffness and swellingSkin: Positive for laceration.

Physical examination:Skin: WoundsSkin wound description: Left shin laceration healing well multiple interrupted

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sutures, Nylon, removed without incident to Steri-Strips applied calf tenderness is noted of pain in the calf with the dorsiflexion of the foot was noted no palpable cord noted some ecchymosis noted to the lateral calf region.

Diagnostic imaging: Duplex scan left lower extremity reviewed.

*Comments: Direct reports of the diagnostic studies have been included in individual rows below for reference.

Medical decision making:Data reviewed: Vital signs; radiology test resultsTreatment plan: We get the wound wet tomorrow done no restrictions follow up with his primary as needed.

Primary diagnosis: Contusion of leg

Disposition:Disposition: DischargedThe decision to discharge the patient was made on: 07/30/YYYY 18:45 hoursDischarge type: HomeCondition on disposition: ImprovedMedications prescribed: Percocet 5/325 325 mg-5 mg oral tablet

Follow-up: Follow-up with your primary care provider.07/30/YYYY Hospital/

ProviderUltrasound duplex scan of left lower extremity:

History: Patient with left calf pain. Evaluate for DVT.

Findings: There is no deep venous thrombosis seen within the left lower extremity including the common femoral vein, superficial femoral vein, popliteal vein and posterior tibial vein. Normal respiratory phasicity, color-flow and compressibility was visualized.

Impression: No evidence of deep venous thrombosis left lower extremity.

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Initial physiatric evaluation:

Chief complaints: The patient presents to the office today for an initial evaluation with chief complaints of neck pain and left leg pain.

History of present illness: This patient was injured in a motorcycle accident on 07/21/YYYY. The patient was riding his motorcycle and states he was wearing a helmet. He was making a right turn, at which point he was hit by a truck that was making a left turn. He fell off his motorcycle but denies any head trauma or loss of consciousness. An ambulance did not present to the scene. He was driven to the emergency room at Mather Hospital by his wife. He underwent an X-ray of the chest and left leg which were negative for fracture. He received sutures for a left leg laceration. He was given Percocet for his pain, sent home on the same day, and advised to follow up. One week later he was seen at Mather where his left leg sutures were removed. He underwent an ultrasound of the left leg which

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was negative for deep venous thrombosis.

The patient is currently complaining of neck pain but denies any radiation of his pain and he denies any upper extremity pain, paresthesias or weakness. He is complaining of diffuse left leg pain which extends proximally from the mid-thigh distally down the left leg and into the left foot. He presents today for further evaluation.

Review of systems: The patient notes left pectoral chest pain but denies any shortness of breath, fever, nausea or vomiting, constipation, diarrhea, headache, dizziness, or change in bowel or bladder habits.

Physical examination:Musculoskeletal exam:Cervical spine: Range of motion flexion 40 degrees (normal 50 degrees), extension 45 degrees (normal 60 degrees), and rotation bilaterally 65 degrees (normal 80 degrees). There is tenderness to palpation over the cervical paraspinal musculature.Left lower extremity: There is no swelling noted but there is tenderness to palpation over the lateral knee joint compartment as well as diffusely in the left lower leg. There is a 7 cm x 2 cm wound with scab formation over the mid anterior tibial area. There is a smaller abrasion with scab formation distal and lateral to the mid anterior tibial wound. There is mild diffuse calf tenderness but there are no palpable cords and Haman's sign is negative. Knee flexion, knee extension, dorsiflexion, and plantar flexion range of motion is full and strength is 5/5. Sensation is mildly decreased over the anterior tibial area.Motor system: Manual muscle strength is 5/5 in all extremities.Muscle stretch reflexes: Reflexes are 2+ in all extremities.Sensory system: Sensation is mildly decreased to light touch and pinprick over the left lower extremity in the anterior tibial area.

Assessment: Status post motorcycle accident on 07/21/YYYY. Cervical spine strain/sprain. Rule out cervical spine disc herniation. Left lower extremity injury with multiple wounds. Left pectoral chest pain

Recommendations: The patient will begin physical therapy 2 days per week, where he will receive moist heat, cold packs, electrical stimulation, and ultrasound and massage therapy to the cervical paraspinals, followed by range of motion and strengthening exercises for the cervical spine and left leg, with the goals of reducing pain, improving range of motion and improving overall function. Precautions for hypertension will be taken. I am advising that he undergo an MRI of the cervical spine to evaluate for any disc herniations causing his pain and limited range of motion. He denies any possibility of having any metal in his body or working with any metal that could have gotten into his eyes.

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I am advising that he see a plastic surgeon for further evaluation and management of his left lower extremity wounds.

He can take Motrin or Aleve as needed for his pain as long as that is okay with his regular medical doctor.

He was advised to follow up with his regular medical doctor or a clinic for any other medical conditions or concerns.

He was advised that should, at any time, any of his pains or problems become more intense, he should report immediately to the nearest emergency room for a more emergent evaluation.

I will reevaluate this patient in 4 weeks or sooner if needed.

Causality: If the above history is correct, then there is a causal relationship between the patient's motorcycle accident on 07/21/YYYY and his above complaints.

Disability: The patient may continue to work as tolerated. I have advised him to be careful and mindful of his injuries and not do any activities that would further exacerbate them.


Initial physical therapy evaluation: “Illegible Notes”

Patient was involved in a MVA last 07/21/YYYY.

Physical therapy evaluation:Pain scale: 3-4/10Subjective findings:Chief complaints: Left cervical pain, left lower leg pain.Type of pain: Constant, deep and localized.Palpation: Tenderness on cervical spine and left leg, guarding on cervical spine and left knee/ankle. Swelling on left leg/shin.

Range of Motion (ROM): Limitation of Movement (LOM) cervical spine Active Range of Motion (AROM) _________ left knee/ankle _______.MMT: Cervical spine _________. Left knee/ankle 4-/5Mobility/ADL status: Mobility __________ with driving.Transfers/gait: ______________________Positive closed wound 3 cm x 2 cm on anterior leg, dry with dressing.

Diagnosis: Strain and sprain of cervical spine Strain and sprain of left lower extremity.

Physical therapy treatment plan: Therapeutic exercises, thermal, electrical, mechanical modalities, massage.

Intervention given:

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Hot Moist Pack (HMP) to cervical spine Electrical Muscle Stimulation (EMS) modulated on cervical spine Therapeutic exercises: ROM, strengthening.

08/12/YYYY-05/08/YYYY

Hospital/Provider

Interim physical therapy sessions:

Diagnosis: Strain and sprain of cervical spine Strain and sprain of left lower extremity.

Intervention given: Hot Moist Pack (HMP), Electrical Muscle Stimulation (EMS) modulated, therapeutic exercises - ROM, flexibility, strengthening, manual therapy, massage therapy.

He received physical therapy on following dates: 08/12/YYYY, 08/15/YYYY, 08/22/YYYY, 08/27/YYYY, 08/29/YYYY, 09/03/YYYY, 09/07/YYYY, 09/08/YYYY, 09/12/YYYY, 09/15/YYYY, 09/20/YYYY, 09/22/YYYY, 09/28/YYYY, 09/29/YYYY, 10/04/YYYY, 10/06/YYYY, 10/18/YYYY, 10/20/YYYY, 10/24/YYYY, 10/29/YYYY, 11/09/YYYY, 11/11/YYYY, 11/12/YYYY, 11/15/YYYY, 11/17/YYYY, 11/21/YYYY, 11/23/YYYY, 11/29/YYYY, 12/01/YYYY, 12/10/YYYY, 12/13/YYYY, 12/15/YYYY, 12/20/YYYY, 12/22/YYYY, 01/04/YYYY, 01/10/YYYY, 01/12/YYYY, 01/17/YYYY, 01/19/YYYY, 01/24/YYYY, 01/28/YYYY, 01/31/YYYY, 02/04/YYYY, 02/07/YYYY, 02/10/YYYY, 02/15/YYYY, 02/16/YYYY, 02/21/YYYY, 02/23/YYYY, 02/27/YYYY, 03/02/YYYY, 03/06/YYYY, 03/09/YYYY, 03/22/YYYY, 03/24/YYYY, 03/28/YYYY, 04/07/YYYY, 04/11/YYYY, 04/13/YYYY, 04/18/YYYY, 04/20/YYYY, 04/26/YYYY, 04/27/YYYY, 05/03/YYYY, 05/06/YYYY, 05/08/YYYY.

*Comments: Interim visits have been presented cumulatively to avoid repetition and for ease of reference.

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Follow-up visit:

Chief complaint: Patient presents for ongoing medical problems.

History of present illness: Here for follow-up visit. Had MVA on motorcycle, recovering. Complains of poor memory. Vague lightheaded sensation.

Review of system: All systems were negatives.

Physical examination: All systems were normal.

Assessment/plan: Hypertensive disorder – lightheaded sensation resolved. Continue

Benicar 20 mg 1 tablet per oral for 90 days. Memory impairment – had recent memory disturbance since MVA, rare

headaches. MRI brain without contrast ordered. Referral to neurology.Return to office: To see Dan Kass, MD for primary care follow-up at Primary Care Associates on or around 09/14/YYYY.

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MRI of brain without contrast: 47-48, 358-359

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History: Amnesia status post motorcycle accident 3 weeks ago

Findings: There is no restricted diffusion. No intracranial hemorrhage. There are a few foci of high T2 signal within the subcortical and deep white matter, nonspecific but likely representing chronic small vessel ischemic disease. Ventricles are normal in size and configuration for age. Major intracranial flow voids are intact. Globes are normal in appearance. Paranasal sinuses are clear. Normal marrow signal within the calvarium.

Impression: No acute intracranial finding.08/25/YYYY Hospital/

ProviderMRI of the cervical spine without contrast:

History: Neck pain

Findings: Normal marrow signal. Vertebral body heights are maintained. Alignment

is anatomic. The cervical cord is normal in caliber and there is no abnormal intrinsic T2

signal. No epidural mass. At C2-C3, there is no significant spondyloarthropathy. At C3-C4, there is a broad-based posterior disc osteophyte complex which

results in mild narrowing of the central canal. There is also mild left neural foraminal stenosis.

At C4-C5, there is a broad-based posterior disc osteophyte complex resulting in mild narrowing of the central canal. There is also moderate right-sided neural foraminal stenosis.

At C5-C6, there is a broad-based posterior disc osteophyte complex resulting in moderate nan-owing of the central canal. There is also moderate bilateral neural foraminal stenosis.

At C6-C7, there is a broad-based posterior disc osteophyte complex without significant narrowing of the central bony canal. There is moderate bilateral neural foraminal stenosis.

At C7-T1, there is no significant spondyloarthropathy.

Impression: Multilevel degenerative disc disease as described above, most pronounced at C5-C6.

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Follow-up visit:

Patient is involved in a motor vehicle accident. He was wearing his helmet. He indicates he was impacted from the left side, thrown to the ground. He was dazed and stunned. He possibly sustained a blunt head injury in spite of his helmet. He injured his left side of the chest, left side of the face, and left leg. Injury took place on 07/22/YYYY (actual date on 07/21/YYYY). Workup was done. No fractures were identified.

In the last six weeks, he has noticed increasing difficulty with his memory. He is being forgetful. He has problem with concentration. He has insomnia. The mood changes are also present. He is irritable, sometimes had difficulty controlling his emotions. Most importantly, he has difficulty finishing his task and feels tired.

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Superimposed neck pain and back pain is also present. The neck pain is still present. The back pain seems to be improving.

Physical examination: Subjective pain and discomfort in his neck and back is present. Range of motion is within normal limits. Reflexes are symmetrical. Gait and station is normal. Tenderness and minimal spasm with limitation in mobility of the neck and back muscles is identified.

Assessment: Head injury with post-concussion syndrome. Cervical pain and cervical spasms, resolving. Low back pain, intermittent lumbosacral pain, and lumbar radiculopathy.

Quite clearly, patient sustained a head injury and possible concussion. His symptoms are most consistent with cerebral concussion and the post-concussion syndrome. There is about 20% improvement in his symptoms, but the problem persists and he remains concerned. I had a detailed discussion with him regarding his problems. I would like to get an MRI of his brain. He will find out if the MRI has already been done and send me a copy of the result. In the interim, he was discouraged from taking any alcohol and/or sleeping pills. He is to avoid excessive reading or watching TV. He should also take over-the-counter medication for his neck pain and back pain. Physical therapy has been helpful and will be continued.

These subjective symptoms in the right upper extremity are suggestive of C6 cervical radiculopathy. This may also explain the numbness in his right hand. This will be monitored clinically.

Re-evaluation in a month with the reports as requested. Right now, the prognosis is guarded.


Follow-up visit:

Patient returns for a follow-up evaluation after being injured in a motorcycle accident on 07/21/YYYY.

Chief complaints: The patient notes intermittent neck pain and he now complains of numbness, tingling, and weakness over the medial aspect of the left arm as well as digits 4 and 5 of the left hand. He continues to note left lower leg and foot pain but is no longer complaining of left upper leg pain.

Physical therapy: The patient has attended 9 sessions of physical therapy thus far and he participates in a daily home exercise program.

Diagnostic studies: The patient underwent an MRI of the cervical spine but the results are unavailable to our office at this time.

Consultations: The patient has been seen by a neurologist.Vocational history: The patient is working on a full-time basis.

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Review of systems: The patient denies any loss of balance or falls.

Physical examination:Musculoskeletal exam:Cervical spine: Range of motion flexion 50 degrees (normal 50 degrees), extension 50 degrees (normal 60 degrees), and rotation bilaterally 70 degrees (normal 80 degrees). There is mild tenderness to palpation over the cervical paraspinal musculature.Left lower extremity: There is a 4 cm x 2 cm wound over the mid anterior tibial area as well as a smaller wound with scab formation distal and lateral to the mid anterior tibial wound. There is no swelling noted but there is diffuse tenderness to palpation of the left lower leg.Motor system: Manual muscle strength is 5/5 in all extremities.Muscle stretch reflexes: Reflexes are 2+ in all extremities.Sensory system: Sensation to light touch and pinprick is decreased over digit 5 of the left hand.

Assessment: Status post motorcycle accident on 07/21/YYYY. Cervical spine strain/sprain. Rule out cervical spine disc herniation.

Evaluate for a cervical radiculopathy versus peripheral neuropathy versus entrapment neuropathy.

Left lower extremity injury with multiple wounds. Left pectoral chest pain which has clinically improved.

Recommendations: The patient will continue physical therapy 2 days per week, where he will receive massage treatment to the neck, followed by range of motion and strengthening exercises for the cervical spine and left leg, with the goals of reducing pain, improving range of motion and improving overall function. Precautions for hypertension will be taken.

Our office will attempt to obtain the results of his cervical spine MRI study and further evaluation and management will be taken based on these results.

I am advising that he undergo electrodiagnostic studies of the upper extremities to evaluate and differentiate between a possible cervical radiculopathy versus a peripheral and entrapment neuropathy causing his pain, symptomatology and signs on examination. The results of these studies will help optimize his physical therapy program and pharmacologic regimen for a better clinical outcome and help determine whether it would be appropriate to refer him for more invasive therapy such as the possibility of epidural steroid injections or perhaps even surgery.

I am advising that he see an orthopedic surgeon for further evaluation and management of his left leg pain.

I am advising that he see a plastic surgeon for further evaluation and management of his left lower extremity wounds.

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He was advised to continue following up with his neurologist.

He can take Aleve as needed for his pain as long as that is okay with his regular medical doctor.



I will reevaluate this patient in 6 weeks’ time.



EMG/nerve conduction study:

Reason for test: Rule out peripheral or entrapment neuropathy versus cervical radiculopathy.

Findings: Evaluation of the left median D2 sensory and the right median D2 sensory nerves showed prolonged distal peak latency (L4.1, R4.2 ms), decreased conduction velocity (wrist-2nd digit, 141, R41 m/s), and decreased conduction velocity (wrist-palm, L35, R33 ms). All remaining nerves (as indicated in the following tables) were within normal limits. F Wave studies indicate that the left median F Wave has prolonged latency (31.12 ms). The left ulnar F Wave has prolonged latency (31.06 ms). All remaining F Wave latencies were within normal limits. Needle EMG examination, performed with a disposable monopolar needle electrode, stored at room temperature prior to testing, revealed denervation potentials including membrane instability, fibrillations, positive sharp waves and abnormal waveform morphology as noted on the attached EMG table. Both proximal and distal limb temperatures were measured and maintained at or above thirty-two degrees Celsius during entire electrophysiological examination.

Impression: The electrodiagnostic study reveals evidence of left cervical spine radiculopathy and bilateral median sensory demyelinating entrapment neuropathies consistent with bilateral carpal tunnel syndrome.

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Interim note:

Patient underwent electrodiagnostic studies at our office on 09/26/YYYY. Electrodiagnostic studies of the cervical paraspinals and upper extremities revealed a left C8 radiculopathy and bilateral median sensory demyelinating entrapment neuropathies consistent with bilateral carpal tunnel syndrome. Based on the results of this study, cervical traction will be added to his physical therapy program.

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In addition, he was advised to follow up with a pain management specialist for further evaluation and management of his cervical radiculopathy.

I will re-evaluate this patient as scheduled.10/03/YYYY-02/07/YYYY

Hospital/Provider

Multiple office visits:

10/03/YYYY: Presents for ongoing medical problems of essential hypertension, memory impairment, and umbilical hernia referred to general surgery.

02/07/YYYY: He feels foggy in the morning, as though he was drugged and sensation of lightheadedness and hypertensive disorder

*Comments: The above visits are not related to subjective injury hence not elaborated.

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Follow-up visit:

Since the last evaluation, he has been going for physical therapy. He recently had a nerve condition study done. I do not have any report for review.

Clinically, his head injury and concussion symptoms are much improved. He is functioning. He is able to be independent in self-care.

He continues to have left-sided neck pain along with left upper extremity radiculopathy mostly in the C8-T1 distribution and possible ulnar nerve dysfunction.

Physical examination: Examination shows no muscle loss and no atrophy. Reflexes are symmetrical. Circulation is normal. No skin changes. Tenderness and muscle spasm in the left lower cervical area is noticed.

Recommendations: Continue physical therapy. Consider cervical traction to relieve some of

the symptoms. Consider trigger point injection if there is no lasting improvement with

physical therapy I see no need for surgical intervention at the present time. This will be

kept under supervision pending re-evaluation with the review of nerve conduction test done in another clinic.

No medication given at this time. Prognosis continues to be better. He will be seen in follow-up in a month’s time.

14-15, 83-84


Follow-up visit:


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Chief complaints: The patient complains of intermittent neck pain with numbness, tingling, and weakness of the medial aspect of the left arm as well as digits 4 and 5 of the left hand. He continues to note pain of the left lower leg and foot as well as a sensation of numbness which is episodic in nature.

Physical therapy: The patient attends physical therapy 2 days per week and participates in a daily home exercise program.

Medications: Aleve as needed.

Diagnostic studies: EMG on 09/26/YYYY was reviewed. Our office has yet to obtain the results of his cervical spine MRI study.

Consultations: The patient was advised to see an orthopedic surgeon and plastic surgeon but has not done so as yet.

Vocational history: The patient is working on a full-time basis.


Physical examination:Musculoskeletal exam:Cervical spine: Range of motion flexion 50 degrees (normal 50 degrees), extension 55 degrees (normal 60 degrees), and rotation bilaterally 70 degrees (normal 80 degrees). There is tenderness to palpation over the cervical paraspinal musculature.Left lower extremity: There is a scar over the medial lower leg with an opening at the distal aspect. There is swelling over the anterior tibial area. There is no tenderness to palpation at this time.Motor system: Manual muscle strength is 5/5 in all extremities.Muscle stretch reflexes: Reflexes are 2+ in all extremities.Sensory system: Sensation to light touch and pinprick is decreased over digits 4 and 5 of the left hand.

Assessment: Status post motorcycle accident on 07/21/YYYY. Cervical spine strain/sprain and a left C8 radiculopathy. Evaluate for

cervical spine disc herniation. Left lower extremity injury with multiple wounds.

Recommendations: The patient will continue physical therapy 2 days per week, where he will receive massage treatment to the cervical spine, followed by range of motion and strengthening exercises for the cervical spine and left leg, with the goals of reducing pain, improving range of motion and improving overall function. Precautions for hypertension will be taken. Cervical traction will be discontinued as the patient could not tolerate this treatment.

Our office will again attempt to obtain the results of his cervical spine MRI study and further evaluation and management will be taken based on these results.

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I am advising that he see an orthopedic surgeon for further evaluation and management of his left lower extremity pain.

I am again advising that he see a plastic surgeon for further evaluation and management of his left lower extremity wounds.

I am advising that he see a pain management specialist for further evaluation and management of his cervical radiculopathy.




I will reevaluate this patient in 6 weeks' time.



Follow-up visit: (Illegible notes)

Chief complaint: MRI brain seen. Headache decreased 75%, dizziness decreased 75%, left arm numbness.

History of present illness: Still has cervical spine and lumbar spine pain. Able to function. Working.

Examination: Cervical spine ROM slow with pain. Still has decreased ROM cervical spine. Slow improvement.

Diagnosis: Left arm radiculopathy noted Head injury improvement noted

Plan: No medications OTC medications ok. Discontinue for cervical spine - _______. Return to clinic in 6 weeks.

85


Follow-up visit:


Chief complaints: The patient complains of intermittent neck pain with numbness, tingling, and weakness of the medial aspect of the left arm as well as

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digits 4 and 5 of the left hand. He continues to note pain and weakness of the anterior aspect of the left leg.



Diagnostic studies: The patient had undergone an MRI of the cervical spine at Mather Hospital which revealed multi-level degenerative disc disease which is most pronounced at C5-C6. This study was discussed and reviewed with the patient.



Physical examination:Musculoskeletal exam:Cervical spine: Range of motion flexion 50 degrees (normal 50 degrees), extension 60 degrees (normal 60 degrees), and rotation bilaterally 70 degrees (normal 80 degrees). There is tenderness to palpation over the cervical paraspinal musculature.Left lower extremity: There is a scar over the medial lower leg with swelling noted over the anterior tibial area. There is diminished sensation to light touch and pinprick over the anterior tibial area. There is no tenderness to palpation at this time.Motor system: Manual muscle strength is 5/5 in all extremities.Muscle stretch reflexes: Reflexes are 2+ in all extremities.Sensory system: Sensation to light touch and pinprick is decreased over digits 4 and 5 of the left hand.

Assessment: Status post motorcycle accident on 07/21/YYYY. Cervical spine disc derangement with left C8 radiculopathy. Left lower extremity injury with multiple wounds.

Recommendations: The patient will continue physical therapy 2 days per week, where he will receive massage treatment to the cervical spine, gentle cervical traction, range of motion and strengthening exercises, with the goals of reducing pain, improving range of motion and improving overall function. Precautions for hypertension will be taken.

I am again advising that he see an orthopedic surgeon for further evaluation and management of his left lower extremity pain.


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I am again advising that he see a pain management specialist for further evaluation and management of his cervical radiculopathy.







Follow-up visit:


Chief complaints: The patient complains of intermittent neck pain with numbness, tingling, and weakness over the medial aspect of the left forearm as well as over digits 4 and 5 of the left hand. He notes ongoing pain and weakness of the anterior aspect of the left leg.





Physical examination:Musculoskeletal exam:Cervical spine: Range of motion flexion 50 degrees (normal 50 degrees), extension 60 degrees (normal 60 degrees), and rotation bilaterally 70 degrees (normal 80 degrees). There is tenderness to palpation over the cervical paraspinal musculature.Left lower extremity: There is a scar over the medial lower leg with some swelling noted over the anterior tibial area. There is diminished sensation to light touch and pinprick over the anterior tibial area. There is no tenderness to palpation at this time.Motor system: Manual muscle strength is 5/5 in all extremities.Muscle stretch reflexes: Reflexes are 2+ in all extremities.

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Sensory system: Sensation to light touch and pinprick is decreased over digits 4 and 5 of the left hand.

Assessment:

Status post motorcycle accident on 07/21/YYYY. Cervical spine disc derangement with left C8 radiculopathy. Left lower extremity injury with multiple wounds.

Recommendations: The patient will continue physical therapy 2 days per week, where he will receive moist heat and massage treatment to the cervical spine, gentle cervical traction, range of motion and strengthening exercises, with the goals of reducing pain, improving range of motion and improving overall function. Precautions for hypertension will be taken.

I am again advising that he see an orthopedic surgeon for further evaluation and management of his left lower extremity pain.


I am again advising that he see a pain management specialist for further evaluation and management of his cervical radiculopathy.







Physical therapy final visit:

Subjective: Pain scale: 2/10Patient reports reduced neck pain since last visit.

Objective: Positive for tenderness over the bilateral upper trapezius.

Assessment: Tolerated treatment well.

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Plan: Continue the plan of care.

Interventions given: Hot moist pack, manual therapy - myofascial release, therapeutic exercises – ROM, flexibility.


Follow-up visit:

History of present illness: The patient presents with a complaint of knee problem. The onset of the knee problem has been gradual and has been occurring in a persistent pattern for 1 months. The course has been gradually worsening. The knee problem is described as being located in the left. The knee pain was caused by no apparent injury The pain is described as stabbing. The pain is worse when walking a moderate amount. The symptoms have been associated with medial pain and painful ROM. Previous diagnostic tests include plain radiographs. Previous evaluations include orthopedic surgeon. There has been no previous physical therapy. Previous surgeries have included arthroscopic debridement. There is no use of assistive devices. Note for knee problem: Left knee scoped in 2010 by Dr. XXXX. He states his right Total Knee Arthroplasty (TKA) is doing extremely well. He is happy with it. Has no issues.

Review of systems: All other systems negative.

Physical examination: The physical exam findings are as follows: Right knee scar noted. No signs of infection noted left knee varus alignment.Musculoskeletal:Lower extremity: Knee/patella

Passive range of motion Right LeftFlexion 120o 120o

Extension 0o 0o

Palpation: Tenderness - left - over the medial joint line. Inspection and palpation: Effusion - trace, right and left.

Assessment: Primary osteoarthritis of left kneeCurrent plans:

Knee X-ray, 3 view left, routine Knee X-ray, 2 view right, routine Surgery booking form, routine Patient education: Osteoarthritis: Degenerative.

140-141


Correspondence:

Patient was seen on Wednesday, 08/16/YYYY for a periodic recall dental examination and X-rays and has no dental infections and is dentally healthy.

117, 142


Patient profile:

General pain information:Presence of pain: Complains of pain/discomfort

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Pain location: Left kneePain numeric at rest score: 7/10Comfort function goal: 5/10Lifestyle changes/adaptations in response to pain: Inability or reluctance to perform basic ADLs/instrumental ADLs

Chronic pain:Chronic pain: YesPain body location: Left kneeDescription of pain (frequency/quality): ConstantPain rating with rest: 7/10Pain rating with activity: 7/10Comfort function goal: 5/10Chronic pain duration: 1 yearFactors that aggravate pain: ActivityFactors that relieve pain: Medications, rest

Current health and illness:Reason for admission as stated by patient: Left knee medial unicondylar knee replacement.


X-ray of left knee 2 views and single frontal view of hips to ankles:

History: Pain

Findings: Anatomic alignment. No acute fracture or dislocation. Moderate tricompartmental osteoarthritis of the left knee. Status post right total knee arthroplasty. The right femur measures 52.9 cm and the right tibia 43.4 cm for a total right lower extremity length of 97.5 cm. The left femur measures 53.1 cm and the left tibia 43.5 cm with a total left lower extremity length of 96.9 cm. Soft tissues are unremarkable.

Impression: Degenerative changes of the left knee. Measurements as above.

350-353


Echocardiogram:

Ventricular rate: 67 BPMP-R Interval: 224 msQRS Duration: 114 msQ-T Interval/ QTC Calculation Bezet: 400/422 msP-R-T axes: -11-10-7 degrees

Findings: Sinus rhythm with 1st degree A-V block When compared with ECG of 07/21/YYYY 18:21, no significant change

was found

354


Pre-operative medical clearance:

Reason for visit: Patient is here for medical clearance for left knee partial replacement with Dr. XXXX@ Mather on 09/12/YYYY.

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History of present illness: Patient presents for medical clearance prior to his partial left knee replacement with Dr. XXXX at Mather Hospital on 09/05/YYYY. He is feeling well and offers no acute complaints, other than his chronic left knee pain.

Review of systems: Patient reports ability to climb at least 1 flight of stairs without stopping; limitation due to left knee pain.

Physical examination:Abdomen: Bowel sounds: Normal. Inspection and palpation: No tenderness, guarding, or rebound tenderness and soft and non-distended; positive small reducible umbilical hernia noted.

Assessment & plan:Pre-surgery evaluation: Pre-operative labs and EKG have been reviewed. EKG shows 1st degree heart block. Patient has never of having this in the past, no EKG available for comparison. Cardiac clearance will be needed prior to surgery.Patient is to take his Benicar the morning of his surgery with small sip of water. He is to stop Aleve 7 days prior, may take Tylenol as needed for pain. Avoid vitamins, minerals and herbal supplements.Patient is cleared pending cardiac clearance and recommendations.Encounter for other pre-procedural examination

First degree atrioventricular block: Patient to be evaluated by cardio- requires cardiac clearance. Has appointment 09/07/YYYY with Dr. Gor 09:15 am at North Suffolk Cardiology.Atrioventricular block, first degree - send for cardiology referral.

Hypertensive disorder: Blood pressure under excellent control today. He is to continue Benicar 20 mg daily

Heart murmur: Has not had echo done in approximately 6 years.

Follow-up: Patient care extended follow-up scheduled on 12/11/YYYY to establish care with Dr. XXXX.

09/01/YYYY-09/11/YYYY

Hospital/Provider

Call documentation:

09/01/YYYY @ 0340 hours: Received medical clearance for patient stating he is clear pending cardiac clearance. Attempted to call patient to make sure he is awake left message to call PST back.

09/11/YYYY @ 1410 hours: Called Harborview Primary Care Social Worker (S/W) Lindsay regarding medical clearance needs addendum to reflect cardiology clearance. To send urgent message to Nicole, PA to complete note and will fax when completed. Aware of need for note completed today as patient scheduled for operating room in morning.

256

09/07/YYYY Hospital/ Pre-procedure cardiac evaluation: 119-122, 146-149

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Provider Chief complaints: Abnormal EKG. Encounter For Pre-procedural cardiovascular examination.

History of present illness: I was asked by Dr. XXXX to perform a cardiovascular consultation regarding the patient’s pre-procedural cardiovascular examination.

Patient with a history of hypertension (for 15 years) who presents to the office for further evaluation of preoperative cardiovascular risk prior to undergoing planned left knee surgery.

He reports feeling generally well from a cardiac perspective. He states that he was told he had an abnormal ECG on pre-surgical testing. His ECG was performed at Mather Hospital on 08/21/YYYY and it revealed sinus rhythm with a first-degree AV block without any ST or T wave abnormalities. He is fully active physically though he states that he used to walk quite a lot at work but now he primarily drives and doesn't get much exercise. He does not experience any exertional dyspnea or lower extremity edema but he does state that he has intermittent non-exertional and exertional chest discomfort. He reports that he had sharp right-sided chest pain when he was driving recently results reported very infrequent exertional heaviness in his chest when lifting heavy things at work.

A 12-lead ECG was done today given history of chest pain that revealed the following:

Sinus rhythm @73 beats per minute Normal axis First-degree AV block No significant ST or T wave abnormalities When compared to the prior ECG dated 8/21/YYYY from Mather

Hospital, there is no appreciable change.

Review of systems:Respiratory: Complains of dyspnea with exertion.Cardiovascular: Complains of chest discomfort, complains of palpitations, denies peripheral edema, denies syncope episodesNeurological: Complains of dizziness, complains of headaches

Physical examination: All systems were normal

Diagnosis: Essential hypertension Pain in left knee Shortness of breath Other chest pain Dizziness and giddiness Abnormal electrocardiogram (ECG) (EKG) Encounter for pre-procedural cardiovascular examination

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Orders: Lexi scan: First available EKG with interpretation report Return visit in 3 months.

Impressions/plan: Patient appears clinically stable from a cardiovascular perspective. He does have atypical chest discomfort for further risk stratification. He will undergo stress testing. He reports because of his knee pain he is unable to do an exercise treadmill stress test and therefore he will undergo risk stratification with Lexi scan nuclear stress test.

I have asked the patient to check and record his blood pressure/heart rate approximately 1 hour after he takes his anti-hypertensive medication. The patient was advised that he should be sitting for approximately 15 minutes before he checks his blood pressure. The patient will provide recorded values of his home blood pressure readings at the time of his next office visit.

If the above-mentioned stress test reveals normal myocardial perfusion he may proceed with the planned left knee surgery has a low cardiovascular risk for this low surgical risk procedure. I recommend peri-procedural goal systolic blood pressure of < 140 mmHg, with a goal heart rate of 65-70 beats per minute.I will follow up with him in 3 months for blood pressure evaluation and I have asked the patient to contact the office if he has any questions, concerns, or changes in his cardiac-related symptoms.


Lexi scan stress myocardial perfusion study:

Indications: Chest pain, abnormal EKG, risk stratification partial left knee replacement 09/12/YYYY

Study type: Lexi scan a pharmacological stress test since the patient is unable to ambulate on a treadmill.

Clinical history: Hypertension, sleep apnea.

Impression: Normal myocardial perfusion, no evidence of ischemia or infarction. Regional wall exam appears abnormal. Gated SPECT Left Ventricular Ejection Fraction (LVEF) is 45%.

Normal LVEF in males > 45%. No previous study for comparison. Based on the results of the nuclear stress imaging the patient may

proceed with the planned left knee surgery having a low cardiovascular risk for this low surgical risk procedure.

Moderately enlarged LV volumes with the Left Ventricular End-Diastolic Volume (LVEDV) = 228 ml and ESV = 126 ml. Normal volumes in males are LVEDV < 142 ml and Left Ventricular End- Systolic Volume (LVESV) < 65mls.

Results will be discussed with the patient and forwarded to my colleague Dr. Chirayu Gor.

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Addendum:

Cardiac clearance received from Dr. McBrearty. Patient had negative nuclear ST 09/08/YYYY, cardiovascular risk and is cleared for proposed surgery.

116


Anesthesia record:

Diagnosis: Left knee osteoarthritis

Procedure: Left knee unicondylar arthroplasty.

Anesthesiologist: Brian Cook, MD

Site marked: Left

Monitors: EKG, blood pressure, SaO2, EtCO2Oxygen: 3 L/min, nasal cannula.

Procedure note: Skin anesthetized with local anesthetic. Patient position: Supine, sterile prep, sterile drape, Chlorhexidine.

Premedication: Midazolam 2 mg. patient sedated easily aroused and conversant.Nerve block: Adductor Canal Block (ACB) leftTechnique: Single, ultrasound.Needle/size: 21 gauge 4 inch

Local anesthetic: Bupivacaine 0.5%, Epinephrine 1/200 k.

Event: Easy, well tolerated

Times:Anesthesia start time: 1133 hoursProcedure start time: 1218 hoursProcedure end time: 1443 hoursPost-Anesthesia Care Unit (PACU): 1450 hours to 1458 hours.

Anesthesia details: Regional for post-operative painType: Subarachnoid block (SAB)Level: L3-L4Position: SittingAgent: Betadine Prep x 3Positive for cerebrospinal fluid.

166-167, 200, 255


Operative report:

Pre and post-operative diagnosis: Left knee medial degenerative joint disease.

Operation: Computer-assisted robotic left unicondylar knee replacement.

Surgeon: Michael XXXX, MD

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Anesthesia: Spinal and adductor canal block, Brian Cook, MD09/12/YYYY Hospital/

ProviderIntraoperative nursing record:

Pre and post-operative diagnosis: Left knee osteoarthritis

Procedure: Left knee medial unicondylar arthroplasty.

Anesthesia start time: 1133 hoursProcedure start time: 1218 hoursProcedure end time: 1443 hoursAnesthesia end time: 1451 hours

Pre-operative:Patient admitted to or via: AmbulatePatient identification: OralLevel of consciousness: Alert and oriented, cooperativePre-procedure briefing-sign: YesNothing by mouth since: 23:59 hoursPatient data reviewed and is in compliance with hospital policy: YesPatient orientated and educated to or procedure and intraoperative nursing interventions: YesAnxiety reduction techniques implemented: Yes

Intra-operative:Patient transferred to: Operation room table.Comments: Demayo positioner being used, Eggcrate under right legSafety strap on: Yes, across chestPosition for anesthesia: SupineCorrect body alignment maintained: Yes.Position for surgery: SupineRight and left positioning device: Eggcrate paddingSkin condition: Intact, scar to left shinPositioning devices applied and checked according to operative room positioning policy: YesAll pressure points checked: YesElectro cautery: Covidien Electrosurgical Unit (ESU) unit 8 at right thighVenous stasis prevention: Intermittent pneumatic compression device and right thigh highTourniquet: Smart pumpTemperature monitoring: HypothermiaPatient monitoring: Blood pressure, pulse oximetry, EKG, temperature.

Medications: Cefazolin 2 gm. IV Vancomycin 1 gm. IV

Post-operative: Patient moved to bed.

Medication/irrigations:

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0.25% Marcaine with Epinephrine local route 0.9% Sodium Chloride (Nacl) irrigation 150,000 units of Bacitracin in 3 liters of 0.9% irrigation Sterile water on field


PACU record:

Surgical procedure: Left knee medial unicondylar arthroplasty

Time:PACU time in: 09/12/YYYY 02:50:00 pmPACU time out: 09/12/YYYY 05:47:00 pmPACU total time: 2 hours, 57 minutes

Anesthesia type: Spinal

Patient condition and vital signs: StableDischarge criteria met for PACU: Yes

176, 182-199

09/12/YYYY-09/13/YYYY

Hospital/Provider

Operative related records:

Pre-operative checklist, pre-surgical testing, history and physical, pre-operative aspiration prophylaxis, orders, flow sheet, labs, patient education, assessments, plan of care, medication sheets, discharge instructions, discharge reconciliation.

Pdf-ref: 102-103, 106-108, 130, 160-163, 178-181, 212-254, 260-300, 307-32309/12/YYYY Hospital/

ProviderBrief post-operative note:

Admitting diagnosis: Arthritis of knee.Procedure: Unicondylar knee replacement using computer navigation

Brief post-operative report:Anesthesia: Nerve block; spinalEstimated blood loss: 200 cc TT 94 minuteComplications: NoneSpecimens pending: NoneFindings: Right knee medial compartment Degenerative Joint Disease (DJD)

Procedure performed: Left knee medial unicondylar arthroplasty injection 0.25% Marcaine with Epinephrine

VTE risk and prophylaxis: Patient is high risk with no contraindications.

201


Physical therapy progress note:

Patient’s chart reviewed, patient out of operative room at approximately 14:30 hours, call placed to PACU at 15:30 and 16:10 patient not appropriate for Out of Bed (OOB) at this time. South assistant nurse manager Ann made aware, and email sent to Mary Ann Goodman that patient will not be seen by physical therapy today. RN assist manager reporting patient will get up with nursing. Will follow.

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Occupational therapy progress note:

Multiple attempts made to see patient this evening. As per PACU nurse - patient is still too lethargic to stand at this time, and remains in the PACU. Will attempt to follow patient next morning as patient tolerates.

206


X-ray of left knee 2 views:

History: Status post knee surgery.

Findings: Patient has undergone interval medial compartment hemiarthroplasty. No evidence of fracture, dislocation or loosening. Tracts from prior hardware is noted within the distal femoral shaft. Bony mineralization is within normal. No osseous lesions. Suprapatellar joint effusion and air is noted consistent with postoperative change. No unintentional radiopaque foreign body.

Impression: Status post left medial compartment hemiarthroplasty without acute

complication. Soft tissue postoperative changes.

164-165


Orthopedic coordinator progress notes @ 16:31 hours:

Rounded in PACU. Patient alert, oriented. Called M SuzziValli, PA about Ancef and Tranexamic acid order. Ancef to be given 5 doses and Tranexamic acid to be given 3 doses total. Reviewed plan of care with PACU RN and 3 South RN.

@ 16:35 hours: Patient alert, oriented in PACU. Left Total Knee Replacement (TKR) dressing dry, intact. Positive circulation checks, Full sensation not returned fully as yet. Reviewed plan of care with PACU RN and 3 South RN.

09/13/YYYY @ 10:23 hours: Rounded on patient on 3 South. Patient alert, oriented-Out of Bed (OOB) in chair. Patient’s pain at 2. Relieved with medications. Patient left TKR dressing clean and dry. Positive circulation checks, positive neurovascular checks. Patient perform physical therapy, ankle pumps and incentive spirometer. Patient voiding and passing gas. Patient educated on Enteric Coated Aspirin, VTE prophylaxis including pneumatic compression devices are utilized by patient, signs & symptoms of complications reviewed. Patient verbalizes understanding via teach back method to nurse. The patient verbalizes willingness to make this lifestyle change on a blood thinner for the short period of time. The patient verbalizes willingness to follow this treatment. Spoke with RN in charge of patient's care, physical therapist, and social worker reviewed patient’s plan of care. The orthopedic coordinator reviewed Long Island Health Network (LIHN) patient educational material with patient. The patient was given a self-management plan for recovery. Patient demonstrated understanding by teach back.

09/13/YYYY @ 10:29 hours: Patient instructed after having a joint replacement a patient must be proactive in preventing infection in them. Patient instructed must take an antibiotic before any dental work, colonoscopies, and any sign of infection seek medical care. The patient was instructed if they develop a

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temperature of 100.5 or greater, any drainage or foul odor from the incision call the orthopedic surgeon. Reviewed with patient dressing can be removed from the third day after surgery. Can shower but no tub baths. If any bleeding from anticoagulant notify surgeon, patient demonstrated understanding by teach back method. Patient scheduled to be discharge today.


Consultation report@ 16:31 hours:

Chief complaint: Medial left knee pain, convalescence following elective left partial knee replacement.

History of present illness: Patient underwent elective partial left knee replacement by Dr. XXXX at JTMMH. As per patient, he has been experiencing worsening left medial knee pain for the past 3-4 months even at rest. Patient works as equipment supervisor that requires lots of driving. He reports pain at rest and worsened with ambulation. He denies any previous trauma to area. He denies experiencing dyspnea/chest pain/heart palpitations/dysuria prior to elective surgery. Currently patient reports experiencing bladder fullness as if he needs to pee (per RN, end up voiding). He reports decreased sensation in bilateral lower extremities.

Review of systems:Neurological: Positive symptoms – paresthesias, numbness in lower extremities.

Physical examination:Musculoskeletal: Unable to assess ROM or strength since post-op.Extremities: Normal extremities, no cyanosis. No post-operative wrappings on bilateral lower extremities.

Assessment/plan:Problem 1: Convalescence following surgeryPlan: Patient underwent elective partial left knee replacement by Dr. XXXX, medicine consulted for convalescence following surgery. ECG with 1-st degree AV block.

Vital Signs Stable (VSS). Follow-up morning labs. Currently denies anginal symptoms/dyspnea.

Antibiotics (abx) as per ortho surgery. Consistent With (C/W) incentive spirometry, pain management per ortho surgery. Venous Thromboembolism (VTE) Prophylaxis (ppx) per surgery.

Senna/Colace as needed for constipation. Further physical therapy rehabilitation.

Problem 2: HypertensionPlan: Benicar 20 mg home regimen. Hold when signs/symptoms of worsening renal failure.Plan: Venous Thromboembolism (VTE) prophylaxis: As per ortho surgeryDiet: Regular

154-159


Nursing progress notes @ 18:18 hours:

Post-operative: Patient transferred from PACU at 1800, transferred in bed. Vital

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Signs Stable (VSS), documented in chart. IV in left arm, Within Normal Limits (WNL), fluids infusing. Patient complaining of pain 5/10 in left knee, per PACU nurse was recently given Oxycodone 5mg. Dressing to left knee clean dry intact. Skin assessment performed with Anne L, RN, WNL. Patient stood at bedside, steady on feet with walker, ambulated to chair and back. Bed placed in lowest position, bed alarm on, call bell within reach. Will continue to monitor.

Nursing progress note @ 03:24 hours: Patient is alert and oriented x4. Status post unicondylar knee replacement on 9/12. Vitals stable and every 4 hours neuro checks Within Defined Limits (WDL). IV fluids discontinue because patient was able to tolerate per oral intake. Patient currently resting in bed, Continuous Positive Airway Pressure (CPAP) machine on. All safety checks in place. Will continue monitoring.


Physician progress note @ 0905 hours:

History of present illness: Patient is status post left medial unicondylar arthroplasty. Patient doing well and comfortable. Patient denies any chest pain/tightness, shortness of breath, calf pain or paresthesias.

Admitting diagnosis: Arthritis of knee.Procedure: Unicondylar knee replacement using computer navigationVisit problem: Convalescence following surgery

Physical examination:Examination of left lower extremity: Dressing is Clean Dry and Intact (C/D/I). No warmth, erythema or discharge noted. Calf is soft, nontender, sensation is intact. AT/Gastro Soleus (GS)/Extensor Hallucis Longus (EHL)/ Flexor Hallucis Longus (FHL) 5/5. Pulses are palpable.Examination of right lower extremity: Calf soft, nontender, Neurovascularly Intact Distally (NVID) grossly.

Plan: Physical therapy Weight Bearing as Tolerated (WBAT) Left Lower

Extremity (LLE)/Bone foam to left heel when in bed or chair Deep Vein Thrombosis (DVT) prophylaxis on Aspirin (ASA) twice a

day. Continue medical management If ok with medicine and physical therapy discharge home with home

care/physical therapy Follow-up with Dr. XXXX in 2 weeks.

132-133, 136-137


Physician progress note@ 1258 hours:

Admission justification: The patient continues to need inpatient care due to as per ortho.

History of present illness: Patient underwent elective partial left knee replacement by Dr. XXXX at JTMMH. As per patient, he has been experiencing worsening left medial knee pain for the past 3-4 months even at rest. Patient works as equipment supervisor that requires lots of driving. He reports pain at

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rest and worsened with ambulation. He denies any previous trauma to area. He denies experiencing dyspnea/chest pain/heart palpitations/dysuria prior to elective surgery. Currently patient reports experiencing bladder fullness as if he needs to pee (per RN, end up voiding). He reports decreased sensation in bilateral lower extremities.Seen at bed side, feels fine, has no acute complaints, no bowel movements but passing gas, denies nausea, vomiting, shortness of breath, chest pain, urinary complaints, fever chills.

Physical examination:Musculoskeletal: Unable to assess ROM or strength since post-op.Extremities: Normal extremities, no cyanosis. No post-operative wrappings on bilateral lower extremities

Plan: Patient underwent elective partial left knee replacement by Dr. XXXX, medicine consulted for convalescence following surgery. ECG with 1-st degree AV block.

Status post left knee replacement Antibiotics (abx) as per ortho surgery. Consistent With (C/W) incentive

spirometry, pain management per ortho surgery. Venous Thromboembolism (VTE) Prophylaxis (ppx) per surgery.

Senna/Colace as needed constipation. Further physical therapy rehabilitation. No contraindication for discharge from medical stand point

Plan: Hypertension: Benicar 20 mg. BP controlledPlan: Venous Thromboembolism (VTE) Prophylaxis: As per ortho surgery. Regular diet.


Physical therapy initial evaluation:

Physical therapy initial evaluation for rehabilitation: YesGeneral observations: Patient with pain in left knee 2-3/10 with activityPertinent history of current problem: Prior to Arrival (PTA) patient reported was I with ambulation and Activities of daily living (ADLS) without an Acute Distress (AD), owns a Rolling Walker (RW) and crutches from previous symptoms, lived in house with 2 steps to enter and 1 flight inside, both with railing.Weight-bearing status: Weight-bearing as tolerated; left lower extremities.

Admitting diagnosis: Arthritis of knee.Visit problem: Convalescence following surgery

Cognitive status examination:Orientation: Orientation to person, place and timeLevel of consciousness: AlertFollows commands and answers questions: Able to follow multi-step instructions.

Range of motion examination: Within Functional Limits (WFL). Patient bends

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knee to 90o in sitting and 0 in extendingManual Muscle Test (MMT) results: > or = 3+/5 grossly throughout. Patient able to perform Straight Leg Raise (SLR).

Bed mobility skill: Supine to sitLevel of independence: IndependentPhysical assistance/nonphysical assistance: 2 person assistance

Transfer skill: Sit to standLevel of independence: IndependentAssistive device: 2 wheeled walker; axillary crutches

Gait assessment:Level of independence: IndependentWeight-bearing restrictions: Weight-bearing as toleratedAssistive device: 2 wheeled walker; axillary crutchesGait distance: 300 feet; 300’ x2

Modified Rankin scale: 2 = Slight disability; unable to carry out all previous activities, but able to look after own affairs without assistance

Clinical impression Physical therapy diagnosis: Difficulty with ambulation.Assessment: Patient went up and down 1 flight of stairs using left then right rail, patient performed with crutch non-reciprocally with 1, therapeutic exercises reviewed and positioning, will follow pending discharge.Anticipated discharge disposition: Home; outpatient physical therapy vs. home.


Occupational therapy initial evaluation:

General information Patient profile review: Yes; left knee unicondylarReferring physician: Dr. XXXXGeneral observations: Patient received supine in bed, complains of 1-2/10 pain. Patient lives with his wife and 2 sons in a 2 level house with 10 steps, bedroom upstairs. Patient has a tub, comfort height toilet. Prior to Admission (PTA): Patient independent with ADL & IADL tasks, also he drives.

Precautions/limitations: Fall precautionsWeight-bearing status: LLE; weight-bearing as tolerated


Clinical impressionOccupational therapy diagnosis: Joint painPrognosis: GoodFunctional level at time of evaluation: GoodPatient/family goals statement: Return home.Criteria for skilled therapeutic interventions met: Yes; treatment indicated

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Rehab potential: Good, to achieve stated therapy goalsTherapy frequency: DailyPredicted duration of therapy intervention (days/weeks): 1-2 daysAnticipated discharge disposition: Home; home with assistanceDemonstrates need for referral to another service: Physical therapy; social work

Previous level of functionBed mobility/transfers: IndependentBathing, upper and lower body dressing, grooming, toileting eating, home management skills were independent

Cognitive status examination:Orientation: Orientation to person, place and timeLevel of consciousness: AlertFollows commands and answers questions: 100% of the time; able to follow multi-step instructions.Personal safety and judgment: IntactShort and long term memory: Intact

Range of motion examination: No ROM deficits were identifiedManual Muscle Test (MMT) results: No strength deficits were identifiedPhysical assist/nonphysical assist assistance: Patient declined Out of Bed (OOB)/standing at this time, independent with physical therapy.

Light touch sensation:Left and right upper extremities: Within normal limits

Upper and lower body dressing training:Level of independence: Independent

Grooming training Level of independence: Independent

Planned therapy interventions: ADL retraining; Instrumental Activities of Daily Living (IADL) retraining; balance training; bed mobility training; transfer training.


Social work initial assessment @ 1039 hours:

General information:Meets high risk criteria? YesHigh social risk screen: Joint replacements.


Living environment:Lives with: Spouse; dependent childrenLiving arrangements: House

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Provides primary care for: No oneQuality of family relationships: SupportiveAble to return to prior living arrangements: YesFeels safe living in home: Yes

Functional status/IADL (Instrumental Activities of Daily Living):Medications, meal preparation, housekeeping, shopping, oral care, MD appointment: Assistive equipment

Major change/loss/stressor: NoneSources of support: Adult children; dependent children; spouseReaction to health status: AcceptingUnderstanding of condition/treatment: Adequate understanding of medical condition

Discharge needs assessment:Equipment currently used at home: Straight cane; crutches; walker; Continuous Positive Airway Pressure (CPAP)Equipment needed after discharge: NoneTransportation available: Family or friend will provide

Current actions taken: Provided emotional support

Social work plan: Social work met with patient in room to educate to social work role and discuss discharge planning. Patient was alert & oriented x3. Patient is status post partial left knee replacement. Patient stated he lives in house with spouse and two dependent children with 10 steps to enter home and 10 steps to bedroom and main bathroom. Patient stated he was independent. With ADL’S, drove and used no Durable Medical Equipment (DME) Prior to Arrival (PTA). Patient stated he does have Rolling Walker (RW), crutches and straight cane at home from prior symptoms. Patient stated he has history of HC with VNS HC but stated he wants to go to outpatient physical therapy upon discharge. Social work spoke to PA Mike who provided script for such. Patient's discharge plan is home without patient physical therapy. No further social work interventions are needed. Contact social work should any needs arise.


Nutrition evaluation:

Diet orders: Regular diet

Initial assessment:Nutritional consult: YesLabs reviewed: Yes; Sodium (Na) 135, Glucose 164, Calcium 8.6Medications reviewed: Yes; IV Dextrose, Colace, Reglan, ZofranDiet history: YesFactors contributing to nutrition status: NoDehydration risk? NoBMI (kg/m2): 29.1

Energy intake: Estimated from reported intake; reported as % of estimated

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energy needsEnergy intake: Good (>75%)

Estimated needs: Weight used if different than above adjusted Body Weight (BW) 92 kg, 25 calories per 92 kg = 2300 estimated calorie needs to 28 calories per 92 kg = 2576 estimated calorie needs, 1 grams of protein per 92 kg = 92 estimated protein needs to 1.2 grams of protein per 92 kg = 110 estimated protein needs, 25 ml fluid per 92 kg = 2300 estimated fluid needs.

Weight assessment: Weight loss (reported as % from baseline): No.

Evaluation/plan:This patient meets criteria for: No malnutritionIntervention: Visited patient at bedside. Tolerating regular diet, excellent per oral intake.

Plan of care: Promote per oral intake > or = 75%; monitor; meet preferences.09/13/YYYY Hospital/

ProviderNursing discharge summary:

Discharge date/time: 09/13/YYYY @ 13:15 hoursPlan: HomeDischarge activity: Ambulate with assistanceDischarge dressing care: Keep wound clean and dryDischarge bathing: Sponge bath onlyDischarge diet: Regular dietOther restrictions: Remove dressing tomorrow. Do not remove plastic adhesive mesh. Use bone foam to left heel when in bed or chair. If no drainage from knee in 1 week, may shower without covering wounds.Fluid restriction: NoDischarge medication: Discharge medications list provided to patient.

Discharge type: RoutineAccompanied by: SpouseMode of discharge: WheelchairMethod of transportation: Private carDischarge note: Discharged around 1315 via wheelchair accompanied by spouse, VSS, IV Ancef given before discharge, discharged instructions given, hep-lock discharged.

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Clinician call back note:


Discharge medications: Acetaminophen + Oxycodone 325 mg-5 mg Aspirin enteric coated Olmesartan

Discharge diet: Regular diet

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Follow up appointment scheduled with other specialists comments: Will make appointment tomorrow for surgeon follow-up appointment.Home care agency has visited comments: Patient going to outpatient rehabilitation.Durable Medical Equipment (DME) has been delivered: Yes


Attestation report:

Diagnosis: Unilateral primary osteoarthritis, left knee Essential hypertension Sleep apnea, unspecified Presence of right artificial knee joint Cardiac murmur, unspecified Atrioventricular block, first degree

Procedure: Replacement of left knee joint with unicondylar synthetic substitute,

cemented. Computer assisted procedure of lower extremity Robotic assisted procedure of lower extremity, open approach Assistance with respiratory ventilation, less than 24 consecutive hours.

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Final progress notes:

Discharge: To home. Weight Bearing as Tolerated (WBAT)

Follow-up: Follow-up with me in 10 days

Discharge instructions: Keep wound clean and dry

Diet: Regular diet

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Other records:

Admission record, drug utilization report, consent, face sheet, flow sheet, medical bills, patient’s information, photos/photocopy other bills, others.

Pdf Ref: 1-7, 44-46, 51-53, 78-80, 86-100, 118, 151, 177, 202, 324-338, 341-349, 355-357, 362-363, 393-399, 458, 482-494, 586-587.

*Comments: All the significant details are included in the chronology. These records have been reviewed and do not contain any significant information. Hence not elaborated.

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€¦ · web viewpatient history. past medical history: hypertension, mitral valve prolapse...

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