Orthopedics Case Study

CHART NOTE

The patient was last seen by me in the office.  The patient was continued on an off-work status until the current recheck.  At that time I requested authorization from the compensation company to carry out an arthroscopic examination of the patient’s left knee under general anesthesia in the near future, with a patellar shaving and removal of any significant marginal spurs at the patellofemoral joint, and if there is a torn meniscus, then partial meniscectomy on an outpatient basis.

Today the patient indicated his left knee is “the same.”  He said he “can’t walk normal.”  He said at times if he will “step wrong” or if he is “walking on a flat surface, something goes out of whack” in the left knee.  He said then he has to stop and move the knee around and then he can go again.  He said it “feels like it doesn’t track right in there.”

The orthopedic examination revealed the circumferences of the thighs, measured (with the knees flexed to a right angle) from the popliteal flexion crease to the suprapatellar area, right over left, to be 15-1/2 inches over 16 inches.  The circumferences of the legs at the level of maximum girth, right over left, were 14-3/4 inches over 14-1/2 inches.  The knee and ankle jerks were brisk and equal bilaterally.  Pinprick in the lower limbs is normal and equal bilaterally.  With regard to the left knee, he had good collateral stability at 180 degrees of extension.  He had a moderate collateral laxity at 160 degrees of extension on the left, and at 90 degrees of flexion he had a negative drawer sign on the left.  The left knee extended fully to 180 degrees and flexed through a range of 135 degrees or to
45 degrees greater than a right angle.  There was moderate subjective tenderness at the medial joint line of the left knee and at the left infrapatellar area and at the left medial patellar margin.  With the left knee extended and the quadriceps mechanism relaxed, the examiner manipulated the patella in a proximal-distal direction as well as in a medial-lateral direction, and the patient complained of some discomfort emanating from the patellofemoral joint with manipulation of the knee in both of these directions.

RECOMMENDATIONS AND/OR TREATMENT

I felt the patient had reached a permanent and stationary status and was ready for rehab.  It was noted he did not want any further surgery on his knee at the present time or in the near future.

FOOTNOTE

Line 9 (Page 1).  The comp company is the workers’ compensation insurance carrier.

Lines 26-28 (Page 1).  Rather than using the slash mark (/) to represent the word over, the values were expressed as transcribed above for clarity.

Lines 31-33 (Page 1).  The knee joint can show good collateral stability at 180 degrees of extension because of the posterior capsule, but collateral laxity can appear at other degrees of extension.