MEDICAL SCENARIO FOR PARTS 1 & 2 FINAL PROJECT Assignment Reading: 1. AMBULATORY CARE FACE SHEET Admit Date: 7/8/20XX @ 20:22 Discharge Date/Time: 7/9/20XX @ 10:10 Sex: M Age: 47 Disposition: Home Admitting Diagnosis: Possible torn meniscus of the left knee. Discharge Diagnosis: Left Knee meniscectomy. Procedures: Laparoscopic Surgery to the Left Knee. CONSULTATION Date of Consultation: 7/8/20XX This is a 47-year-old male who was in his usual state of health until today entered the Emergency Room with severe pain to his left knee and equal amount of edema within the patellar area.
This occurred after the patient fell at an angle on the left knee during a game of football with friends. The patient was evaluated with L-Knee Radiograph and Magnetic Radiograph Imaging (MRI) for soft-tissue films. The L-Knee X-Ray revealed no fractures to the Femur, Patella, Tibia, or Fibula. The MRI revealed a large tear surrounding the meniscus of the left knee. The patient was treated with a left knee splint and crutches with a prescription for Mobic 15mg daily and Tramadol/APAP 37. 5 mg every 4-6 hours for pain. The patient was referred to Orthopedics for surgical repair.
He has no past history of tobacco abuse, previous fractures, or surgeries. 2. Past Medical History: Allergies: No known drug allergies. Medications: None. Surgeries: None Medical History: History of Chronic Otitis Externa Family History: Noncontributory. Review of Systems: No medical abnormalities. Physical Examination: Vital Signs: BP 130/80, P 92, T 98. 5 General: This is a well-developed and well-nourished anxious black male in mild distress. Head and neck are normocephalic and the oropharynx is clear. The left knee shows 5+ edema and patient is unable to bend at knee joint connection.
The patient’s left leg is not weight bearing and the pain level continues to be a 6 to 7 on the pain scale. The patient is using crutches and wheelchair for mobility. All other musculoskeletal joints are with free range of motion. Neurologic with no focal deficits. Impression: Inpatient laparoscopic surgery for total left knee meniscectomy. Local anesthetic total block of the patellar region. 3. OPERATIVE REPORT Date of Procedure: 7/8/20XX Procedure: Laparoscopic Meniscectomy of Left Knee Preoperative Medication: Demerol 50 mg IV, Robinal 3 mg IV, Xylocaine with 1% Epinephrine Preoperative Diagnosis: . Total Left Knee Meniscus Tear. Postoperative Diagnosis: Laparoscopic Meniscectomy of Left Knee Clinical Note: This is a 47-year-old black male with a total meniscus tear of the left knee caused by a causal game of tag football. The patient felt a pop after falling on the left knee at an angle causing severe pain and edema. The patient was taken to the emergency room for x-rays of the left leg and MRI to the left patellar region. He was referred to the othropedics clinic for laparoscopic surgery to the left knee meniscus.
Findings: After obtaining informed consent, he was premedicated with Demerol, Robinal, Xylocaine with 1% Epinephrine without any complications. The patients’ left knee was laparoscoped in the meniscus and the anterolateral and anteromedial parapatellar portholes. The synovium in the suprapatellar pouch showed moderate to severe inflammatory changes with villi formation and hyperemia. Similar changes were noted in the intercondylar groove. The patient tolerated the procedure well, and his post-procedure vital signs are stable. Recommendations: 1. Clear liquids for 24 hours. 2. Follow-up in the office in 2 days.