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

Dear (blank),

Thank you very much for referring this 33-year-old male to me.  He states he has had neck problems ever since he was a young child.  As he has gotten older, they have gotten worse.  He saw an orthopedist at one time who gave him a collar.  He saw a chiropractor for about a year, which did help, but he could no longer financially afford it as he is not working at the present time.  He has not seen the chiropractor for about a year.

The pain is mostly in the posterior aspect of the base of the skull and right side of the neck.  Sometimes it gives him headaches.  He has had no regular physical therapy.  He has had some wrist pain in the past on the left side, which he said had some calcium deposits which were treated with a cast and a splint.

On examination, he has some tenderness on the right base of the skull along the right side of his neck.  His range of motion is just about normal.  Reflexes are intact.

X-rays of his neck, including flexion/extension films, show what appears to be an exostosis or osteoma at the base of the skull.  This seems to be pretty much in the midline.  I am not sure whether this is causing his problems.  The disk space and foramen otherwise look completely normal.

We are going to start some regular physical therapy, and he will get back in touch with me as needed.

Again, thank you very much for referring this patient to me.

Sincerely yours,

Name.

FOOTNOTE

Line 13.  Re was not dictated but was added to demonstrate proper letter format.

Line 22.  Change them to it, referring to He saw a chiropractor in line 21.

Line 39.  Alternative:  Disc.

Orthopedics Studies

Dear Ms. (blank),

I reviewed the set of records which you forwarded to me along with your letter.

Following the medical record review, I find that her right shoulder pain and neck pain began as a result of her work.  It is my impression that there were no other causes of her pain since the record fails to indicate causes other than the one connected with her job.  There is no prior history of similar symptoms.  The loading and unloading of the food containers and bags weighing up to 70 pounds in an individual who is only 5 feet tall and weights 108 pounds is obviously an excessive effort and predisposes her to injury.

As long as the medical record fails to indicate any other prior injuries or any other accidents, one has to assume that all of her symptoms began as a result of a cervical disk herniation, and that she has neurologic changes, and that an EMG and MRI are indicated to complete her diagnostic studies.

Sincerely yours,

Name.

FOOTNOTE

Line 13.  Re was not dictated but was added to demonstrate proper letter format.

Line 32.  Alternative:  Disc.

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 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.