Orthopedics Case Study

EMERGENCY ROOM REPORT

SUBJECTIVE

This patient sustained a laceration to his left index finger with an X-ACTO knife approximately 10 minutes prior to arrival in the emergency room.  The patient’s last tetanus immunization was greater than 5 years ago.  He noted no loss of sensation in the distal digit and noted that he is right-hand dominant.

OBJECTIVE

Findings reveal a 4-cm laceration in a V shape with the apex of the cut towards the distal digit on the radial aspect of the digit.  There was no loss of sensation in the distal digit.  There was heavy bleeding noted, and a Penrose drain tourniquet was applied.  Hemostasis was thence obtained, and the wound was irrigated with Betadine and saline followed by copious amounts of saline.  There was no evidence of tendinous involvement, and full flexion was observed as well as extension.  The wound was explored, and the digital nerve was identified and seemed to be intact, although it was very nicely exposed.  Several small digital rays were observed to have been severed.  The wound was closed.  The wound was dressed with Polysporin.  An aluminum splint was applied.

ASSESSMENT

A 4-cm V-shaped laceration, radial aspect of left index finger, sutured.

FOOTNOTE

Line 9.  The brand name X-ACTO is spelled in all capital letters on the packaging and product; however, it may be written with upper and lowercase letters, X-Acto.

Line 25.  Although the word ray can refer to a finger, it also is defined as “any of a system of parts radially arranged.”  Thus, the physician could be referring to nerves, tendons, vessels, or other radial structures in the hand when he states that several small digital rays were observed to have been severed.

Orthopedics Case Studies

DISCHARGE SUMMARY

ADMITTING DIAGNOSIS

Admitting diagnosis was a nonunion of a fracture of the right radius, status post gunshot wound to the right forearm.

Operative procedures performed included a bone graft to the right radius from the iliac crest.

Briefly reviewing the patient’s admitting history, physical, and hospital course, he was admitted to the hospital for a bone grafting of the right radius from the right iliac crest.  Patient was status post gunshot wound to the right forearm with a segmental bone loss.  Patient was taken to the operating room, underwent the operative procedure without any difficulty.  Postoperatively he had an uneventful postoperative course and was subsequently discharged home to be followed up as an outpatient in my office.

DISCHARGE DIAGNOSIS

Discharge diagnosis included nonunion of fracture of the right radius, status post gunshot wound to the right forearm.

FOOTNOTE

Lines 7, 8.  “Admitting diagnoses was” was edited to “admitting diagnosis was” for proper subject-verb agreement.

Line 26.  The final sentence regarding the operative procedures performed (previously dictated in line 11) was deleted.

Orthopedics Study

Her arm shows forward flexion of about 90 degrees, abduction
60 degrees, external rotation 20 degrees, internal rotation
50 degrees, a well-healed scar.  X-ray shows healing and good maintenance of the fracture.  She is to continue with the range of motion exercises.  She may need the Rush rod removed at some time.  I will see her back here in about 3 months.

CHART NOTE

Her shoulder is improving with PT (physical therapy).  However, she still seems to have restrictions.  She can forward flex about 70 degrees to 80 degrees.  Abduction is only 50 degrees.  She probably has an element of adhesive capsulitis at this time.  She is going to continue her therapy.  In the future she may be a candidate for decompressive acromioplasty if the pain continues.

CHART NOTE

Seen approximately 5 weeks after a fracture of left humerus.  He has been in medial and lateral plaster slabs.  Today there seems to be a slight prominence laterally at the humerus, but the arm seems to be moving as a unit and it is not particularly tender.  X-rays shows some lateral angulation to the humerus, but definitely some callus formation.  I think that even with the deformity, it is mild, and I think the function will be very good.  He is therefore willing to leave things alone at the present and let it heal, and I will see him again in approximately 6 weeks.  He does not need a splint as long as he is careful with the arm.

CHART NOTE

Doing better.  She had the ulnar collateral ligament of her thumb repaired.  She now has almost symmetrical range of motion, but it is still somewhat tight.  It is not particularly painful.  The repair seems solid.  I think she just needs to work on the mobility a little bit longer and that she will be okay.  She will call me in about 2 months to let me know how she is doing.

CHART NOTE

Having a little pain over the distal radial ulnar joint when she lifts something.  There was no popping or clicking.  She has good range of motion and no deformity.  I suggested she just get a small weight and do some strengthening exercises and obtain a splint for her wrist, and she will call and let me know how this is going in the near future.

FOOTNOTE

Lines 7-9 (Page 1).  The degree word was added for clarity.

Line 19 (Page 1).  Alternative:  70-80 degrees.  The degrees word was added to 50 for clarity.

Line 32 (Page 1).  The word callus in the context functions as a noun, not an adjective; the physician is referring to the information of callus.

Line 36 (Page 1).  So as long as was edited to as long as. 
Alternative:  So long as.

Line 44 (Page 1).  She was changed to it for clarity.

Orthopedics Case Studies

Comes to clinic today with problems with recurrent bursitis.  He states that he did make an appointment to see me several weeks ago because of 1 episode of bright red bleeding per rectum.  He states he had never had this occur before, and it has not occurred since.  I discussed the different possibilities of this condition.  He has definitely decided not to pursue the matter.  He is asymptomatic at this time.

What is troubling him at this time is recurrent tendinitis to the left arm (this has been injected successfully with cortisone on multiple occasions), as well as intermittent problems of left hip pain, which also seems to be tendinitis/bursitis in nature.  Smokes 2 packs of cigarettes per day and continues to do so despite a rather severe episode of bronchitis earlier this year.

On examination, he is in no acute distress.  Blood pressure 120/74.  HEENT clear.  Chest clear.  Cardiac examination reveals regular rate and rhythm without murmur.  Patient has marked trigger point on the lateral epicondyle.  He is asymptomatic to his hip at this time, and examination is benign.

After discussing the different possibilities, elected to try conservative therapy.  Tennis elbow armband is placed to the left arm.  He is begun on Anaprox DS on a trial basis.  If this gives adequate relief, I would just have him use it on a p.r.n. basis.  If, however, he continues to have significant pain, would recommend return to clinic for trigger point injection.

FOOTNOTE

Line 19.  Has continues was edited to continues.

Orthopedics Study

DIAGNOSIS

Status post ganglionectomy, left wrist.

PRESENT SUBJECTIVE COMPLAINTS

At this point the patient is approximately 5 months postoperative ganglionectomy of the dorsal left wrist.  Patient states for the past 2 weeks she has experienced some aching and pain in the left wrist.  She gives no history of strain or pull.  She also has complaints referable to the pinkness in color of the incisional scar over the left wrist.

EXAMINATION

Examination reveals the incisional scar to be most acceptable, although very slightly pink.  There is no recurrence of the ganglion.  The patient appears to have good range of motion of the wrist and digits.

COMMENTS

Photographs of the patient were obtained.  If this patient persists in subjective complaints, I would suggest a second opinion be obtained.  I cannot account for her subjective complaints.  My physical findings are not commensurate with her subjective complaints.  The patient will be seen in followup again in about 3 months.

FOOTNOTE

Line 25.  The dictated number 1 was deleted, since additional numbers were not given.