Practicode II (101-200)
Terms in this set (100)
MEDICAL RECORD
SEX: MALE Age: 38DATE OF OPERATION: 1/1/20XXPREOPERATIVE DIAGNOSIS:
COMMINUTED AND DISPLACED FRACTURE OF THE RIGHT TIBIA-MID
SHAFT.PROCEDURES: LOCKING, INTRAMEDULLARY ROD FIXATION-FRACTURED
RIGHT TIBIA; STRYKER.1. ROD-375 X 9-MM.2. PROXIMAL SCREW-40 AND 45 X 5-
MM.3. DISTAL SCREW-35 X 5-MM.POSTOPERATIVE DIAGNOSIS: COMMINUTED
AND DISPLACED FRACTURE OF THE RIGHT TIBIA-MID
SHAFT.SURGEON:ANESTHESIA: GENERAL.ANESTHESIOLOGIST:PROCEDURE: After
adequate induction with general anesthesia and the patient in supine position, a
pneumatic tourniquet was applied to the high right thigh region and not inflated.
The right lower extremity was scrubbed, prepped with Betadine and draped in
the usual manner for lower extremity surgery. An Esmarch tourniquet was applied
CaseID: OPD6933
to the right lower extremity, which was elevated for a period of two minutes. The
Primary Diagnosis: S82.251A
pneumatic tourniquet was inflated to the appropriate level and the Esmarch
CPT: 27759-RT
tourniquet removed.A 2-inch linear incision was made over the patellar tendon
which was split in the midline. Appropriate retraction was applied and a limited
portion of the infrapatellar fat pad was excised. Under the guidance of the image
intensifier, a guidewire was introduced into the proximal right tibia, followed by
application of the proximal drill. The drill and guide wire were both removed, and
a ball-tip guide was introduced into the proximal tibial fracture fragment and
advanced to the fracture site. Utilizing the manual technique, fracture alignment
was achieved, and the ball-tip guide was advanced into the distal fragment. The
guidewire was advanced to the appropriate level and measured proximally. The
appropriate length nail was selected. An un-reamed device was utilized.The 375-
mm x 5-mm unreamed rod was attached to the guide. The IM rod was advanced
through the proximal and distal fracture
, MEDICAL RECORD
AGE: 82SEX: MALEDate of Service: 1/1/20XXService Department: Orthopedic Group
GeneralOPERATIVE NOTE:PREOPERATIVE DIAGNOSIS: Primary Osteoarthritis right
hip.POSTOPERATIVE DIAGNOSIS: Primary Osteoarthritis right hip.NAME OF
PROCEDURE: Right AML Pressfit metal-on-metal total hip
arthroplasty.SURGEON:ASSISTANT:DESCRIPTION OF PROCEDURE: The patient was
given 1 gm of vancomycin slowly IV, then a general anesthetic. He was placed in the
right lateral position where his right hip and lower extremity prepped and
draped in the usual sterile fashion. Spacesuits were used.A straight lateral approach
was made and carefully carried down to the fascia lata which was split. Bleeders
were cauterized. A Charnley retractor was placed in the anterior one-half of the
CaseID: OPD6934 gluteus medius and minimus freeing the greater trochanter. The capsule was
Primary Diagnosis: M16.11 opened anterolaterally in a T-shaped fashion.The hip was dislocated. The neck was
CPT: 27130-RT sectioned at the appropriate level for the AML component. The acetabular
ligament was excised. We irrigated with PB solution, removed the anterior lip
and then we deepened and reamed to a 58-outside diameter. The wound was
thoroughly irrigated with PB solution and then the spiked pore coated 58 outside
diameter AML cup was impacted in 15 degrees of anteversion and a hole
eliminator was applied. The wound was irrigated with PB solution and a 40 inside
diameter metal-on-metal component was impacted.Attention was turned to the
proximal femur which was prepared with the reamers and broaches to accept a
standard 12. The wound was again irrigated with PB solution. Then the standard
fully coated standard 12 AML component was impacted in the neutral position.
There was a proximal crack medially and we passed on 2-mm cerclage wire to keep
this crack from propagating. Trial reduction with a +5 gave excellent stabilit
MEDICAL RECORD
AGE: 64 SEX: MALEDate of Service: 1/1/20XXService Department: Orthopedic Group
GeneralOPERATIVE NOTE:PREOPERATIVE DIAGNOSIS: Primary Degenerative
arthritis of both knees.POSTOPERATIVE DIAGNOSIS: Primary Degenerative arthritis
of both knees.NAME OF PROCEDURE: Bilateral total knee
arthroplasty.SURGEON:DESCRIPTION OF PROCEDURE: The patient was taken to the
operating room after satisfactory general anesthesia, both knees were
thoroughly scrubbed, prepped and draped in the usual sterile manner. The right
knee was operated on first. The leg was elevated and exsanguinated and the
tourniquet about the upper thigh was inflated to 300 mmHg.The knee was incised
longitudinally on the anterior aspect of the knee. The incision was deepened through
CaseID: OPD6935 the subcutaneous tissue to the rectus femoris. The interval between the rectus and
Primary Diagnosis: M17.0 the vastus medialis was incised. This incision was carried down the medial
CPT: 27447-50 border of the patella and patellar tendon. The patella was everted and dislocated
laterally. The knee was then prepared with the Johnson & Johnson instruments to
hold a size 4 femoral component, a size 4 tibial component with a 10-mm thick
polyethylene insert and a 38-mm patellar prosthesis. After finishing all the bone
cuts, a trial reduction demonstrated excellent range of motion and good stability.
The trial prosthesis was therefore removed, and the tourniquet was released.
Hemostasis was obtained with electro cauterization. The leg was then re-elevated
and exsanguinated and the tourniquet reinflated. The bone surfaces were
thoroughly cleansed with the pulsating lavage system. The cement was mixed. It
was pressurized over the bony surfaces and the respective prostheses cemented in
position. Any excess cement was removed in the hardening time.The wound was
then with irrigated with antibiotic solution. The polyethylene
, MEDICAL RECORD
Age: 82 Sex: MALEDate of Service:1/1/20XXService Department: Orthopedic Group
GeneralPREOPERATIVE DIAGNOSIS: Chronic methicillin-resistant Staphylococcus
aureus infected right total knee replacement arthroplasty.POSTOPERATIVE
DIAGNOSIS: Chronic methicillin-resistant Staphylococcus aureus infected right total
knee replacement arthroplasty.NAME OF PROCEDURE: Irrigation, debridement,
washing out with Betadine and drainage of wound.SURGEON: Dr. MDDESCRIPTION
CaseID: OPD6945 OF PROCEDURE: The patient was taken to the operating room and after satisfactory
Primary Diagnosis: T84.53XA general anesthesia his right knee was thoroughly scrubbed, prepped and
Secondary Diagnosis: B95.62 draped in the usual manner. The arthroscope was inserted through the medial
CPT: 29871-RT superior portal, advanced to the pouch. The arthroscopic shaver was inserted
laterally and Ringer's lactate run through the knee. The shaver was used to debride
the abundant scar tissue. The knee was copiously irrigated with Ringer's lactate. I
then ran Betadine solution through the knee. This was held in place for
approximately 3 minutes and then was washed out copiously using large volumes of
Ringer's lactate and shaving. The wound was irrigated with antibiotic solution once
more. He subsequently had the wounds closed with four staples after evacuating
all excess fluid. The patient was taken to the recovery room in satisfactory
condition.Electronically signed by 1/1/20XX
MEDICAL RECORD
Age 82 Sex: FEMALEDate of Service: 1/1/20XXService Department: Orthopedic
Group GeneralPREOPERATIVE DIAGNOSIS: Pathological fracture, thoracic spine,
T11.SECONDARY DIAGNOSIS: Osteoporosis T12 (senile osteoporosis).NAME OF
PROCEDURE:1. Percutaneous vertebroplasty, one vertebral body, unilateral, with
cavity creation, including biopsy, thoracic.2. Percutaneous vertebroplasty, one
vertebral body, unilateral, thoracic.SURGEON: Dr. MDANESTHESIA: (MAC).
Monitored AnesthesiaESTIMATED BLOOD LOSS: Negligible.COMPLICATIONS:
None.INDICATIONS: This patient just over a week ago had undergone a
vertebral augmentation procedure by me in the thoracic spine. She did quite
CaseID: OPD6948 well for about 3 days and has come back to my office crying in pain. She cannot
Primary Diagnosis: M80.08XA move. She is just totally disabled in pain, such severe pain that she has asked to be
Secondary Diagnosis: Z98.890 admitted.I have examined her. She has no tenderness at her previous
CPT: 22513-78, 22515-78 vertebroplasty augmentation site. She has marked pain below this. X-rays done in
my office compared to her preoperative x-rays shows that it appears the T11 level
has fractured, and this has started an early collapse. She has osteoporosis at other
levels. This is likely the source of her pain.RECOMMENDATION: I think she should
undergo stabilization of T11, prophylactic fixation of T12. I have discussed this with
her yesterday, and today she has agreed with this plan, especially the prophylactic
fixation.I will go ahead and do this for her. She understands the procedure and risks.
She has already started treatment of osteoporosis.DESCRIPTION OF PROCEDURE:
The patient is transferred onto the OR table. Time-out. Two-plane fluoroscopy,
identification of T11 on the left, T12 on the right. Wash and prep. Sterile draping.
Time-out, antibiotics. Local infiltration of left side T11, right side T12, through the
skin and subcutaneous
, MEDICAL RECORD
OPERATIVE NOTEAGE: 47Sex: FEMALEDOS: 1/1/20XXPHYSICIAN:PREOPERATIVE
DIAGNOSES: Torn lateral meniscus Degenerative.POSTOPERATIVE DIAGNOSES:
Torn lateral meniscus and tear of medial meniscus right knee
degenerative.OPERATIVE PROCEDURES: Arthroscopic partial medial and lateral
meniscectomies and degenerative joint debridement.SURGEON:ANESTHESIA:
General.BRIEF SUMMARY: This lady had a previous partial meniscectomy for a
discoid lateral meniscus in 19XX. She has done well until the past two or three
months, when she has had gradually increasing pain. She clinically had findings
consistent with an internal derangement. A MRI scan was performed, which shows
complex posterior horn lateral meniscus. She is now admitted for
CaseID: OPD6953
meniscectomy.FINDINGS OF SURGERY: A small flap tear in the mid anterior portion
Primary Diagnosis: S83.241A
medial meniscus was encountered, as well as a flap tear in the midportion lateral
Secondary Diagnosis: S83.231A
meniscus and an inferior cleavage tear of the posterior horn of the lateral
CPT: 29880-RT
meniscus. The overall meniscus appeared satisfactory and stable. There were no
peripheral tears. Partial meniscectomy performed medially and laterally. There
was also synovial scarring from the opened procedure.DESCRIPTION OF
PROCEDURE: The patient was anesthetized, placed supine, and given general
anesthesia. The right lower extremity was placed in a leg holder, prepped and
draped in the normal sterile fashion.
Exsanguinated with Esmarch and tourniquet insufflated to 350 mmHg. Arthroscope
was inserted through the lateral portal, instrumentation through the medial portal.
The above findings were noted. Motorized shaver and basket forceps were used to
resect the torn portions of both medial and lateral menisci, tapering to a stable rim.
The motorized shaver was used to remove redundant scar tissue in the anterior
lateral compartment. Once this was accomplished,
MEDICAL RECORD
OPERATIVE NOTEAGE: 61SEX: FemalePHYSICIAN:DOS: 1/1/20XXPREOPERATIVE
DIAGNOSIS: Torn lateral meniscus, right knee.POSTOPERATIVE DIAGNOSIS: Grade 2
and 3 degenerative joint disease, Primary knee.OPERATIVE PROCEDURE:
Arthroscopy, right knee, with tricompartmental articular
debridement.SURGEON:ANESTHESIA:PERTINENT HISTORY INDICATIONS: Patient is
a female, who presented with right knee pain. Last month she evidently stepped up
on the first step of some steps and twisted her right knee and had some pain and
felt a pop there. She was seen in the clinic, where she was found to have a positive
McMurray's laterally with lateral joint line tenderness and a positive Apley
compression test, positive Thessaly test, all laterally. We attempted to get an MRI to
CaseID: OPD6961
confirm our diagnosis; however, she has had metallic implant in the past and we
Primary Diagnosis: M17.11
could not get the MRI performed. After discussing options with her as her knee pain
Secondary Diagnosis: Z96.698
persisted, she elected to come to surgery at this time for an arthroscopy of her right
CPT: 29877-RT
knee for possible torn lateral meniscus and or other type of internal
derangement.PROCEDURE TECHNIQUE: The patient was taken to the operating
theater and placed on the operating table in the supine position, after which the
general anesthetic was administered. Her right lower extremity then was placed into
a thigh holder, after which the proposed portal sites and the knee joint itself
were instilled with 22 mL of an analgesic cocktail containing 15 mL of 0.5%
Marcaine with epinephrine, 15 mL of 1% lidocaine with epinephrine, and 10 mL of
Duramorph. Once this was completed, the right lower extremity was sterilely
prepped and draped in the usual manner. A lateral operative portal was created
with a #11 knife blade as the arthroscope and its cannula were introduced into her
knee joint. Initial examination of the suprapa
Terms in this set (100)
MEDICAL RECORD
SEX: MALE Age: 38DATE OF OPERATION: 1/1/20XXPREOPERATIVE DIAGNOSIS:
COMMINUTED AND DISPLACED FRACTURE OF THE RIGHT TIBIA-MID
SHAFT.PROCEDURES: LOCKING, INTRAMEDULLARY ROD FIXATION-FRACTURED
RIGHT TIBIA; STRYKER.1. ROD-375 X 9-MM.2. PROXIMAL SCREW-40 AND 45 X 5-
MM.3. DISTAL SCREW-35 X 5-MM.POSTOPERATIVE DIAGNOSIS: COMMINUTED
AND DISPLACED FRACTURE OF THE RIGHT TIBIA-MID
SHAFT.SURGEON:ANESTHESIA: GENERAL.ANESTHESIOLOGIST:PROCEDURE: After
adequate induction with general anesthesia and the patient in supine position, a
pneumatic tourniquet was applied to the high right thigh region and not inflated.
The right lower extremity was scrubbed, prepped with Betadine and draped in
the usual manner for lower extremity surgery. An Esmarch tourniquet was applied
CaseID: OPD6933
to the right lower extremity, which was elevated for a period of two minutes. The
Primary Diagnosis: S82.251A
pneumatic tourniquet was inflated to the appropriate level and the Esmarch
CPT: 27759-RT
tourniquet removed.A 2-inch linear incision was made over the patellar tendon
which was split in the midline. Appropriate retraction was applied and a limited
portion of the infrapatellar fat pad was excised. Under the guidance of the image
intensifier, a guidewire was introduced into the proximal right tibia, followed by
application of the proximal drill. The drill and guide wire were both removed, and
a ball-tip guide was introduced into the proximal tibial fracture fragment and
advanced to the fracture site. Utilizing the manual technique, fracture alignment
was achieved, and the ball-tip guide was advanced into the distal fragment. The
guidewire was advanced to the appropriate level and measured proximally. The
appropriate length nail was selected. An un-reamed device was utilized.The 375-
mm x 5-mm unreamed rod was attached to the guide. The IM rod was advanced
through the proximal and distal fracture
, MEDICAL RECORD
AGE: 82SEX: MALEDate of Service: 1/1/20XXService Department: Orthopedic Group
GeneralOPERATIVE NOTE:PREOPERATIVE DIAGNOSIS: Primary Osteoarthritis right
hip.POSTOPERATIVE DIAGNOSIS: Primary Osteoarthritis right hip.NAME OF
PROCEDURE: Right AML Pressfit metal-on-metal total hip
arthroplasty.SURGEON:ASSISTANT:DESCRIPTION OF PROCEDURE: The patient was
given 1 gm of vancomycin slowly IV, then a general anesthetic. He was placed in the
right lateral position where his right hip and lower extremity prepped and
draped in the usual sterile fashion. Spacesuits were used.A straight lateral approach
was made and carefully carried down to the fascia lata which was split. Bleeders
were cauterized. A Charnley retractor was placed in the anterior one-half of the
CaseID: OPD6934 gluteus medius and minimus freeing the greater trochanter. The capsule was
Primary Diagnosis: M16.11 opened anterolaterally in a T-shaped fashion.The hip was dislocated. The neck was
CPT: 27130-RT sectioned at the appropriate level for the AML component. The acetabular
ligament was excised. We irrigated with PB solution, removed the anterior lip
and then we deepened and reamed to a 58-outside diameter. The wound was
thoroughly irrigated with PB solution and then the spiked pore coated 58 outside
diameter AML cup was impacted in 15 degrees of anteversion and a hole
eliminator was applied. The wound was irrigated with PB solution and a 40 inside
diameter metal-on-metal component was impacted.Attention was turned to the
proximal femur which was prepared with the reamers and broaches to accept a
standard 12. The wound was again irrigated with PB solution. Then the standard
fully coated standard 12 AML component was impacted in the neutral position.
There was a proximal crack medially and we passed on 2-mm cerclage wire to keep
this crack from propagating. Trial reduction with a +5 gave excellent stabilit
MEDICAL RECORD
AGE: 64 SEX: MALEDate of Service: 1/1/20XXService Department: Orthopedic Group
GeneralOPERATIVE NOTE:PREOPERATIVE DIAGNOSIS: Primary Degenerative
arthritis of both knees.POSTOPERATIVE DIAGNOSIS: Primary Degenerative arthritis
of both knees.NAME OF PROCEDURE: Bilateral total knee
arthroplasty.SURGEON:DESCRIPTION OF PROCEDURE: The patient was taken to the
operating room after satisfactory general anesthesia, both knees were
thoroughly scrubbed, prepped and draped in the usual sterile manner. The right
knee was operated on first. The leg was elevated and exsanguinated and the
tourniquet about the upper thigh was inflated to 300 mmHg.The knee was incised
longitudinally on the anterior aspect of the knee. The incision was deepened through
CaseID: OPD6935 the subcutaneous tissue to the rectus femoris. The interval between the rectus and
Primary Diagnosis: M17.0 the vastus medialis was incised. This incision was carried down the medial
CPT: 27447-50 border of the patella and patellar tendon. The patella was everted and dislocated
laterally. The knee was then prepared with the Johnson & Johnson instruments to
hold a size 4 femoral component, a size 4 tibial component with a 10-mm thick
polyethylene insert and a 38-mm patellar prosthesis. After finishing all the bone
cuts, a trial reduction demonstrated excellent range of motion and good stability.
The trial prosthesis was therefore removed, and the tourniquet was released.
Hemostasis was obtained with electro cauterization. The leg was then re-elevated
and exsanguinated and the tourniquet reinflated. The bone surfaces were
thoroughly cleansed with the pulsating lavage system. The cement was mixed. It
was pressurized over the bony surfaces and the respective prostheses cemented in
position. Any excess cement was removed in the hardening time.The wound was
then with irrigated with antibiotic solution. The polyethylene
, MEDICAL RECORD
Age: 82 Sex: MALEDate of Service:1/1/20XXService Department: Orthopedic Group
GeneralPREOPERATIVE DIAGNOSIS: Chronic methicillin-resistant Staphylococcus
aureus infected right total knee replacement arthroplasty.POSTOPERATIVE
DIAGNOSIS: Chronic methicillin-resistant Staphylococcus aureus infected right total
knee replacement arthroplasty.NAME OF PROCEDURE: Irrigation, debridement,
washing out with Betadine and drainage of wound.SURGEON: Dr. MDDESCRIPTION
CaseID: OPD6945 OF PROCEDURE: The patient was taken to the operating room and after satisfactory
Primary Diagnosis: T84.53XA general anesthesia his right knee was thoroughly scrubbed, prepped and
Secondary Diagnosis: B95.62 draped in the usual manner. The arthroscope was inserted through the medial
CPT: 29871-RT superior portal, advanced to the pouch. The arthroscopic shaver was inserted
laterally and Ringer's lactate run through the knee. The shaver was used to debride
the abundant scar tissue. The knee was copiously irrigated with Ringer's lactate. I
then ran Betadine solution through the knee. This was held in place for
approximately 3 minutes and then was washed out copiously using large volumes of
Ringer's lactate and shaving. The wound was irrigated with antibiotic solution once
more. He subsequently had the wounds closed with four staples after evacuating
all excess fluid. The patient was taken to the recovery room in satisfactory
condition.Electronically signed by 1/1/20XX
MEDICAL RECORD
Age 82 Sex: FEMALEDate of Service: 1/1/20XXService Department: Orthopedic
Group GeneralPREOPERATIVE DIAGNOSIS: Pathological fracture, thoracic spine,
T11.SECONDARY DIAGNOSIS: Osteoporosis T12 (senile osteoporosis).NAME OF
PROCEDURE:1. Percutaneous vertebroplasty, one vertebral body, unilateral, with
cavity creation, including biopsy, thoracic.2. Percutaneous vertebroplasty, one
vertebral body, unilateral, thoracic.SURGEON: Dr. MDANESTHESIA: (MAC).
Monitored AnesthesiaESTIMATED BLOOD LOSS: Negligible.COMPLICATIONS:
None.INDICATIONS: This patient just over a week ago had undergone a
vertebral augmentation procedure by me in the thoracic spine. She did quite
CaseID: OPD6948 well for about 3 days and has come back to my office crying in pain. She cannot
Primary Diagnosis: M80.08XA move. She is just totally disabled in pain, such severe pain that she has asked to be
Secondary Diagnosis: Z98.890 admitted.I have examined her. She has no tenderness at her previous
CPT: 22513-78, 22515-78 vertebroplasty augmentation site. She has marked pain below this. X-rays done in
my office compared to her preoperative x-rays shows that it appears the T11 level
has fractured, and this has started an early collapse. She has osteoporosis at other
levels. This is likely the source of her pain.RECOMMENDATION: I think she should
undergo stabilization of T11, prophylactic fixation of T12. I have discussed this with
her yesterday, and today she has agreed with this plan, especially the prophylactic
fixation.I will go ahead and do this for her. She understands the procedure and risks.
She has already started treatment of osteoporosis.DESCRIPTION OF PROCEDURE:
The patient is transferred onto the OR table. Time-out. Two-plane fluoroscopy,
identification of T11 on the left, T12 on the right. Wash and prep. Sterile draping.
Time-out, antibiotics. Local infiltration of left side T11, right side T12, through the
skin and subcutaneous
, MEDICAL RECORD
OPERATIVE NOTEAGE: 47Sex: FEMALEDOS: 1/1/20XXPHYSICIAN:PREOPERATIVE
DIAGNOSES: Torn lateral meniscus Degenerative.POSTOPERATIVE DIAGNOSES:
Torn lateral meniscus and tear of medial meniscus right knee
degenerative.OPERATIVE PROCEDURES: Arthroscopic partial medial and lateral
meniscectomies and degenerative joint debridement.SURGEON:ANESTHESIA:
General.BRIEF SUMMARY: This lady had a previous partial meniscectomy for a
discoid lateral meniscus in 19XX. She has done well until the past two or three
months, when she has had gradually increasing pain. She clinically had findings
consistent with an internal derangement. A MRI scan was performed, which shows
complex posterior horn lateral meniscus. She is now admitted for
CaseID: OPD6953
meniscectomy.FINDINGS OF SURGERY: A small flap tear in the mid anterior portion
Primary Diagnosis: S83.241A
medial meniscus was encountered, as well as a flap tear in the midportion lateral
Secondary Diagnosis: S83.231A
meniscus and an inferior cleavage tear of the posterior horn of the lateral
CPT: 29880-RT
meniscus. The overall meniscus appeared satisfactory and stable. There were no
peripheral tears. Partial meniscectomy performed medially and laterally. There
was also synovial scarring from the opened procedure.DESCRIPTION OF
PROCEDURE: The patient was anesthetized, placed supine, and given general
anesthesia. The right lower extremity was placed in a leg holder, prepped and
draped in the normal sterile fashion.
Exsanguinated with Esmarch and tourniquet insufflated to 350 mmHg. Arthroscope
was inserted through the lateral portal, instrumentation through the medial portal.
The above findings were noted. Motorized shaver and basket forceps were used to
resect the torn portions of both medial and lateral menisci, tapering to a stable rim.
The motorized shaver was used to remove redundant scar tissue in the anterior
lateral compartment. Once this was accomplished,
MEDICAL RECORD
OPERATIVE NOTEAGE: 61SEX: FemalePHYSICIAN:DOS: 1/1/20XXPREOPERATIVE
DIAGNOSIS: Torn lateral meniscus, right knee.POSTOPERATIVE DIAGNOSIS: Grade 2
and 3 degenerative joint disease, Primary knee.OPERATIVE PROCEDURE:
Arthroscopy, right knee, with tricompartmental articular
debridement.SURGEON:ANESTHESIA:PERTINENT HISTORY INDICATIONS: Patient is
a female, who presented with right knee pain. Last month she evidently stepped up
on the first step of some steps and twisted her right knee and had some pain and
felt a pop there. She was seen in the clinic, where she was found to have a positive
McMurray's laterally with lateral joint line tenderness and a positive Apley
compression test, positive Thessaly test, all laterally. We attempted to get an MRI to
CaseID: OPD6961
confirm our diagnosis; however, she has had metallic implant in the past and we
Primary Diagnosis: M17.11
could not get the MRI performed. After discussing options with her as her knee pain
Secondary Diagnosis: Z96.698
persisted, she elected to come to surgery at this time for an arthroscopy of her right
CPT: 29877-RT
knee for possible torn lateral meniscus and or other type of internal
derangement.PROCEDURE TECHNIQUE: The patient was taken to the operating
theater and placed on the operating table in the supine position, after which the
general anesthetic was administered. Her right lower extremity then was placed into
a thigh holder, after which the proposed portal sites and the knee joint itself
were instilled with 22 mL of an analgesic cocktail containing 15 mL of 0.5%
Marcaine with epinephrine, 15 mL of 1% lidocaine with epinephrine, and 10 mL of
Duramorph. Once this was completed, the right lower extremity was sterilely
prepped and draped in the usual manner. A lateral operative portal was created
with a #11 knife blade as the arthroscope and its cannula were introduced into her
knee joint. Initial examination of the suprapa
