Orthopedics

He stabilized with only moderate improvement in his bursitis at this time after the series of B12 shots.

Examination shows a decreased adduction of the left arm.  Mild tenderness at the proximal area of the subdeltoid bursa.

Will use Feldene 1 tablet daily for 15 days.  Will send for routine blood work, as he has not had this in quite some time.

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.

Orthopedics Case Study

CHART NOTE

Followup for the complications of osteoporosis as they affect the spine.  She had a 6-month history of progressive, disabling back pain visibly associated with progressive kyphotic deformity of the thoracolumbar spine, with an attendant cervical lordosis.  While the cosmetic deformity was certainly very significant, it was rather her back pain in the midthoracic area that primarily precipitated her visiting me and requesting this consultation.  She advised me that for many, many years she had had a
tea-and-toast diet with a very poor protein intake and admitted to not having consumed milk for many, many years.  Also, because of attendant foot and left knee problems, she had a markedly diminished level of physical activity in the past year and a half, on many occasions being confined to the house for long periods of time.  She also had the habit, as do many patients with osteoporosis, of lying down a great deal during the day to cope with her back pain before finally seeking medical attention.  She advises that she was referred to the osteoporosis center at a nearby hospital where bone densitometry studies were done, and a diagnosis of osteoporosis involving the spine was made, but without evidence at that time of compression fracture.  She was started on calcitonin and vitamin D complex in addition to oral calcium supplements.  This went on for approximately 12 weeks.  At the end of that time, the vitamin D and the calcitonin were discontinued, as is usual, but she was continued on oral calcium and elevated levels of activity.

On physical examination, the patient demonstrated the aforementioned cervical lordosis and thoracic kyphosis.  She was markedly tender over the lower thoracic spine and upper lumbar spine area.  Axial weight loading, particularly with spinal extension forces added, markedly precipitated her pain.  Her neurologic examination in the lower extremities was normal.

We did x-rays of the thoracic spine today even though they were done just 12 weeks ago.  These new films now reveal a
third-degree compression fracture of T11 and a second-degree compression fracture of L1 of the upper lumbar spine.  I advised the patient of this eventuality and that such compression fractures, even without trauma, not uncommonly are complications of underlying osteoporosis as severe as hers.

We are going to place her in a Jewett hyperextension brace, provide analgesics, and continue the same anti-osteoporosis measures afforded.  She will return in 4 weeks’ time for x-ray and further followup.

Orthopedics Study

CHART NOTE

This patient states that he was seen at this pain clinic and was given a lumbar epidural injection 1 week ago.

The patient states that he has not noticed any significant help.

He has again been informed that an implant stimulator was recommended, but the patient does not want this device implanted.

The patient at this time is remaining on medication.

He will return here in 3 weeks.  He is going to pain clinic again for further assessment.

CHART NOTE

The evaluation on the above date indicated that the patient had a history of a lumbosacral sprain, and the clinical assessment and objective findings for the lower back examination did not reveal a neurological or musculoskeletal deficit.  At that time I suggested a CT scan to further correlate with the findings.

I did receive a CT scan of the lumbar spine.  The scan was from L3 to S1 and revealed a normal CT scan of the lumbar spine.  Patient also had an electromyogram performed, which was a normal study.

In view of the clinical objective findings, which indicated no neurological musculoskeletal deficit and excellent function and range of motion of lower back and lower extremity, and in conjunction with the normal CT scan and electromyogram, the patient exhibited no findings which would indicate a permanent or partial permanent disability, and based upon the previous studies, the patient should be able to perform in his usual and customary duties.

FOOTNOTE

Line 30.  Alternative:  L-3 to S-1.

Orthopedics Case STudy

Comes to clinic today to be seen in followup.  She has continued complaints of persistent discomfort to the left rib cage, axillary area, radiating up into the neck and jaw.  When I had last seen her, I felt that she had a costochondritis, possible fibrositis.  I did pursue a workup which included an ANA.  All other laboratory work, which included a thyroid function test and basic fasting panel, proved to be negative.  Sedimentation rate is borderline elevated at 27.  ANA proved to be positive at 1:160.  Panel was negative other than 1:400 for antithyroid microsome.

As I was unsure of the significance of these findings, particularly relating to the patient’s symptoms, I recommended she see a specialist for further evaluation.  She continues to feel that there is something more severely wrong than just fibrositis or costochondritis.  She seems to feel that there is a serious underlying soft tissue problem, although chest x-ray and ECG also proved to be negative.  I honestly feel that the patient has fibrositis.  I do not believe she has lupus, but given her abnormal laboratory work, I think that it is appropriate to seek referral.  I attempted to reassure her and will continue to encourage her to seek a second opinion, via referral, to quiet her anxieties concerning any disease process.

CHART NOTE

The patient is a 39-year-old male with a history of slipped disk.  He has had low back pain for approximately 2 years.  He had chymopapain which provided temporary relief for his slipped disk.  He went back to work, but after 3 weeks he began to have severe low back pain which again radiated down his leg.  He claims that the pain is aggravated by coughing or sneezing.  He complains of occasional weakness and numbness in the left leg.  He also complains of severe pain and discomfort in the right side of his neck and right shoulder, and he has pain when he raises his arm over his head.  He denies any redness, heat, or swelling of his joints.  He had a recent MRI study, which showed disk space degeneration at L1-L2, L2-L3, L3-L4, L4-L5, and L5-S1, with posterior bulging at L4-L5 and L5-S1.  He has a back brace but was told not to use it because it might weaken his abdominal muscles.

Medication consists of Tolectin DS and Fiorinal with codeine.  He had a myelogram done in April.

Physical examination reveals a well-developed male in no acute distress.  Height 5 feet 6-1/2 inches, weight 174, blood pressure 124/74, pulse 72.  Gait and station were normal.  Pulses were 2+.  There were no temperature changes, ulcerations, brawny edema, or varicosities.  Range of motion of all joints was full and within normal limits, except he could only flex his LS spine to 70 degrees and extend it 15 degrees.  The remainder of his range of motion was normal.  Hand grasp was 4/4 bilaterally, and he could perform fine and gross manipulations with both hands.  He walked without assistance.  There was no atrophy, heat, swelling, or deformity of his joints.  There was tenderness on range or motion of the right shoulder and back.  No muscle weakness was noted except for slight weakness on extension of the right leg, but this may be splinting due to his back pain.  Reflexes were 1+ and symmetric.  Straight leg raising was positive at 60 degrees on the left.  There was slight decreased light touch sensation over the left thigh, but light touch was normal distally.  There was no evidence of movement disorder, and he was able to ambulate without assistance.

In summary, the patient is a 39-year-old white male with a history of herniated disk treated with chymopapain, with only temporary relief.  He continues to complain of low back pain which radiates down his leg, associated with intermittent numbness and weakness.

FOOTNOTE

Lines 34, 36, 44  (Page 1), 25 (Page 2).  Alternative:  Disc.