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2,200 | Intramedullary nail fixation of the left tibia fracture with a Stryker T2 tibial nail. Left tibial shaft fracture status post gunshot wound. | Orthopedic | Intramedullary Nail Fixation | TITLE OF OPERATION: , Intramedullary nail fixation of the left tibia fracture with a Stryker T2 tibial nail, 10 x 390 with a one 5-mm proximal locking screw and three 5-mm distal locking screws (CPT code is 27759) (the ICD-9 code again is 823.2 for a tibial shaft fracture).,INDICATION FOR SURGERY: ,The patient is a 19... | orthopedic, screw, stryker, tibia, intramedullary nail fixation, tibial shaft fracture, intramedullary, guidewire, nail, fracture, tibial |
2,201 | Displaced left subtrochanteric femur fracture. Intramedullary rod in the left hip using the Synthes trochanteric fixation nail measuring 11 x 130 degrees with an 85-mm helical blade. | Orthopedic | Intramedullary Rod | PREOPERATIVE DIAGNOSIS:, Displaced left subtrochanteric femur fracture.,POSTOPERATIVE DIAGNOSIS:, Displaced left subtrochanteric femur fracture.,OPERATION: , Intramedullary rod in the left hip using the Synthes trochanteric fixation nail measuring 11 x 130 degrees with an 85-mm helical blade.,COMPLICATIONS:, None.,T... | orthopedic, displaced, femur fracture, subtrochanteric, hip, synthes, intramedullary rod, subtrochanteric femur, trochanteric fixation, helical blade, tourniquet, intramedullary, trochanteric, fixation, helical, blade, guidewire, fracture, |
2,202 | Bilateral knee degenerative arthritis. Bilateral knee arthroplasty. The Zimmer NexGen total knee system was utilized. | Orthopedic | Knee Arthroplasty - Bilateral | PREOPERATIVE DIAGNOSIS: , Bilateral knee degenerative arthritis.,POSTOPERATIVE DIAGNOSIS: , Bilateral knee degenerative arthritis.,PROCEDURE PERFORMED: , Bilateral knee arthroplasty.,Please note this procedure was done by Dr. X for the left total knee and Dr. Y for the right total knee. This operative note will discus... | orthopedic, patellofemoral, eburnation, osteophyte, articulation, tibial, femoral, bilateral knee arthroplasty, knee degenerative arthritis, zimmer nexgen, lower extremity, arthroplasty, patella, methylmethacrylate, |
2,203 | A male presents complaining of some right periscapular discomfort, some occasional neck stiffness, and some intermittent discomfort in his low back relative to an industrial fall. | Orthopedic | IME & Record Review - Orthopedic | INTRODUCTION: , The opinions expressed in this report are those of the physician. The opinions do not reflect the opinions of Evergreen Medical Panel, Inc. The claimant was informed that this examination was at the request of the Washington State Department of Labor and Industries (L&I). The claimant was also inform... | null |
2,204 | Grade 1 compound fracture, right mid-shaft radius and ulna with complete displacement and shortening. Irrigation and debridement of skin subcutaneous tissues, muscle, and bone, right forearm. Open reduction, right both bone forearm fracture with placement of long-arm cast. | Orthopedic | I&D & Open Reduction - Forearm | PREOPERATIVE DIAGNOSIS: ,Grade 1 compound fracture, right mid-shaft radius and ulna with complete displacement and shortening.,POSTOPERATIVE DIAGNOSIS: , Grade 1 compound fracture, right mid-shaft radius and ulna with complete displacement and shortening.,OPERATIONS:,1. Irrigation and debridement of skin subcutaneous... | orthopedic, compound fracture, mid-shaft radius, ulna, open reduction, irrigation and debridement, subcutaneous, tissues, muscle, bone, forearm, radius and ulna, forearm fracture, anatomic alignment, arm cast, puncture wound, tourniquet, i&d, fracture, |
2,205 | Postoperative wound infection, complicated. Irrigation and debridement of postoperative wound infection. Removal of foreign body. Placement of vacuum-assisted closure.device. | Orthopedic | I&D - ORIF Wound | TITLE OF OPERATION:,1. Irrigation and debridement of postoperative wound infection (CPT code 10180).,2. Removal of foreign body, deep (CPT code 28192).,3. Placement of vacuum-assisted closure device, less than 50 centimeter squared (CPT code 97605).,PREOP DIAGNOSIS: , Postoperative wound infection, complicated (ICD-... | orthopedic, irrigation and debridement, removal of foreign body, vacuum-assisted closure device, foreign body, postoperative wound, wound infection, infection, wound, orif, debridement, vacuum, |
2,206 | Persistent left hip pain. Left hip avascular necrosis. Discussed the possibility of hip arthrodesis versus hip replacement versus hip resurfacing | Orthopedic | Hip Pain | CHIEF COMPLAINT:, | orthopedic, hip pain, radiculopathy, degenerative changes, avascular necrosis, hip resurfacing, arthrodesis, hip replacement, avn, |
2,207 | Incision and drainage and removal of foreign body, right foot. The patient has had previous I&D but continues to have to purulent drainage. The patient's parents agreed to performing a surgical procedure to further clean the wound. | Orthopedic | I&D & Foreign Body Removal | PREOPERATIVE DIAGNOSIS:, Foreign body, right foot.,POSTOPERATIVE DIAGNOSIS: , Foreign body, right foot.,PROCEDURE PERFORMED:,1. Incision and drainage, right foot.,2. Removal of foreign body, right foot.,HISTORY: , This 7-year-old Caucasian male is an inpatient at ABCD General Hospital with a history of falling off h... | orthopedic, incision and drainage, removal of foreign body, purulent drainage, foreign body, metatarsal head, metatarsal, i&d, incision, drainage, foot |
2,208 | Non-healing surgical wound to the left posterior thigh. Several multiple areas of hypergranulation tissue on the left posterior leg associated with a sense of trauma to his right posterior leg. | Orthopedic | Hypergranulation - Consult | CHIEF COMPLAINT:, Non-healing surgical wound to the left posterior thigh.,HISTORY OF PRESENT ILLNESS: , This is a 49-year-old white male who sustained a traumatic injury to his left posterior thighthis past year while in ABCD. He sustained an injury from the patellar from a boat while in the water. He was air lifted... | null |
2,209 | Painful ingrown toenail, left big toe. Removal of an ingrown part of the left big toenail with excision of the nail matrix. | Orthopedic | Ingrown Toenail Removal | PREOPERATIVE DIAGNOSIS: , Painful ingrown toenail, left big toe.,POSTOPERATIVE DIAGNOSIS: , Painful ingrown toenail, left big toe.,OPERATION: , Removal of an ingrown part of the left big toenail with excision of the nail matrix.,DESCRIPTION OF PROCEDURE: ,After obtaining informed consent, the patient was taken to the ... | orthopedic, toenail, nail matrix, ingrown toenail, painful, ingrown, |
2,210 | Decreased ability to perform daily living activity secondary to recent right hip surgery. | Orthopedic | Hip Surgery - Discharge Summar | CHIEF COMPLAINT:, Decreased ability to perform daily living activity secondary to recent right hip surgery.,HISTORY OF PRESENT ILLNESS: ,The patient is a 51-year-old white female who is status post right total hip replacement performed on 08/27/2007 at ABCD Hospital by Dr. A. The patient had an unremarkable postoper... | null |
2,211 | Status post left hip fracture and hemiarthroplasty. Rehab transfer as soon as medically cleared. | Orthopedic | Hip Fracture - Rehab Consult | ADMISSION DIAGNOSIS: , Left hip fracture.,CHIEF COMPLAINT: , Diminished function, secondary to the above.,HISTORY: , This pleasant 70-year-old gentleman had a ground-level fall at home on 05/05/03 and was brought into ABCD Medical Center, evaluated by Dr. X and brought in for orthopedic stay. He had left hip fracture ... | null |
2,212 | Hemiarthroplasty of left shoulder utilizing a global advantage system with an #8 mm cemented humeral stem and 48 x 21 mm modular head replacement. Comminuted fracture, dislocation left proximal humerus. | Orthopedic | Hemiarthroplasty - Shoulder | PREOPERATIVE DIAGNOSIS:, Comminuted fracture, dislocation left proximal humerus.,POSTOPERATIVE DIAGNOSIS:, Comminuted fracture, dislocation left proximal humerus.,PROCEDURE PERFORMED: , Hemiarthroplasty of left shoulder utilizing a global advantage system with an #8 mm cemented humeral stem and 48 x 21 mm modular head... | orthopedic, dislocation, proximal humerus, comminuted fracture, rotator interval, tuberosity portion, hemiarthroplasty, fracture, wound, proximal, deltoid, rotator, stem, humeral, humerus, tuberosity, cemented, |
2,213 | Left C5-6 hemilaminotomy and foraminotomy with medial facetectomy for microscopic decompression of nerve root. | Orthopedic | Hemilaminotomy & Foraminotomy | PRE AND POSTOPERATIVE DIAGNOSIS:, Left cervical radiculopathy at C5, C6,OPERATION: , Left C5-6 hemilaminotomy and foraminotomy with medial facetectomy for microscopic decompression of nerve root.,After informed consent was obtained from the patient, he was taken to the OR. After general anesthesia had been induced, T... | orthopedic, foraminotomy with medial facetectomy, facetectomy for microscopic decompression, decompression of nerve root, hemilaminotomy and foraminotomy, decompression of nerve, microscopic decompression, medial facetectomy, kerrison rongeur, nerve root, spinous processes, facetectomy, kerrison, hemilaminotomy, forami... |
2,214 | Left hip fracture. The patient is a 53-year-old female with probable pathological fracture of the left proximal femur. | Orthopedic | Hip Fracture - ER Consult | REASON FOR CONSULTATION: , Left hip fracture.,HISTORY OF PRESENT ILLNESS: , The patient is a pleasant 53-year-old female with a known history of sciatica, apparently presented to the emergency room due to severe pain in the left lower extremity and unable to bear weight. History was obtained from the patient. As per ... | orthopedic, calcar, proximal femur, pathological fracture, hip, fracture, hemiarthroplasty, melanoma, |
2,215 | Austin-Moore bipolar hemiarthroplasty, left hip. Subcapital left hip fracture. | Orthopedic | Hemiarthroplasty - Austin-Moore Bipolar | PREOPERATIVE DIAGNOSIS: , Subcapital left hip fracture.,POSTOPERATIVE DIAGNOSIS: , Subcapital left hip fracture.,PROCEDURE PERFORMED: , Austin-Moore bipolar hemiarthroplasty, left hip.,ANESTHESIA: ,Spinal.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: ,Less than 100 cc.,HISTORY: ,The patient is an 86-year-old female ... | orthopedic, austin-moore bipolar hemiarthroplasty, subcapital left hip fracture, hip fracture, austin moore bipolar hemiarthroplasty, subcutaneous tissues, hip, hemiarthroplasty, austin, cemented, femur, subcapital, fracture, femoral, |
2,216 | Hemiarthroplasty, right hip. Fracture of the right femoral neck, also history of Alzheimer's dementia, hypothyroidism, and status post hemiarthroplasty of the hip. | Orthopedic | Hemiarthroplasty - Discharge Summary | ADMISSION DIAGNOSES: ,Fracture of the right femoral neck, also history of Alzheimer's dementia, and hypothyroidism.,DISCHARGE DIAGNOSES: , Fracture of the right femoral neck, also history of Alzheimer's dementia, hypothyroidism, and status post hemiarthroplasty of the hip.,PROCEDURE PERFORMED: ,Hemiarthroplasty, righ... | orthopedic, femoral neck, orthopedics, rehab, femoral, neck, fracture, dementia, hemiarthroplasty, hip, |
2,217 | Hardware removal in the left elbow. | Orthopedic | Hardware Removal - Elbow | PREOPERATIVE DIAGNOSIS: , Retained hardware in left elbow.,POSTOPERATIVE DIAGNOSIS:, Retained hardware in left elbow.,PROCEDURE: , Hardware removal in the left elbow.,ANESTHESIA: , Procedure done under general anesthesia. The patient also received 4 mL of 0.25% Marcaine of local anesthetic.,TOURNIQUET: ,There is no ... | orthopedic, retained hardware, hardware removal, tourniquet, elbow, hardware, |
2,218 | New patient visit for right hand pain. Punched the wall 3 days prior to presentation, complained of ulnar-sided right hand pain, and was seen in the emergency room. | Orthopedic | Hand Pain - Consult | REASON FOR VISIT: ,New patient visit for right hand pain.,HISTORY OF PRESENT ILLNESS: ,The patient is a 28-year-old right-hand dominant gentleman, who punched the wall 3 days prior to presentation. He complained of ulnar-sided right hand pain and was seen in the emergency room. Reportedly, he had some joints in his... | orthopedic, hand pain, pain, hand, metacarpals |
2,219 | Removal of painful hardware, first left metatarsal. Excision of nonunion, first left metatarsal. Incorporation of corticocancellous bone graft with internal fixation consisting of screws and plates of the first left metatarsal. | Orthopedic | Hardware Removal - Metatarsal | TITLE OF OPERATION:,1. Removal of painful hardware, first left metatarsal.,2. Excision of nonunion, first left metatarsal.,3. Incorporation of corticocancellous bone graft with internal fixation consisting of screws and plates of the first left metatarsal.,PREOPERATIVE DIAGNOSES:,1. Nonunion of fractured first left... | orthopedic, hardware removal, metatarsal osteotomy, painful hardware, osteotomy, excision of nonunion, corticocancellous bone graft, internal fixation, subcutaneous tissues, previous osteotomy, vicryl suture, suture material, corticocancellous bone, ankle tourniquet, bone graft, metatarsal, tourniquet, allograft, fixat... |
2,220 | Hardware removal, right ulnar | Orthopedic | Hardware Removal - Ulnar | PREOPERATIVE DIAGNOSIS: , Retained hardware, right ulnar.,POSTOPERATIVE DIAGNOSIS: , Retained hardware, right ulnar,PROCEDURE: , Hardware removal, right ulnar.,ANESTHESIA:, The patient received 2.5 mL of 0.25% Marcaine and local anesthetic.,COMPLICATIONS: , No intraoperative complications.,DRAINS: , None.,SPECIMENS: ,... | orthopedic, both-bone forearm fracture, retained hardware, hardware removal, hardware, forearm, ulnar, |
2,221 | Left distal medial hamstring release. | Orthopedic | Hamstring Release | PREOPERATIVE DIAGNOSIS: , Autism with bilateral knee flexion contractures.,POSTOPERATIVE DIAGNOSIS: , Autism with bilateral knee flexion contractures.,PROCEDURE: , Left distal medial hamstring release.,ANESTHESIA: , General anesthesia. Local anesthetic 10 mL of 0.25% Marcaine local.,TOURNIQUET TIME: , 15 minutes.,ESTI... | orthopedic, medial hamstring release, distal medial hamstring release, bilateral knee flexion contractures, bilateral knee, hamstring release, knee flexion, tourniquet, flexion, contractures, hamstring, |
2,222 | Excision of foreign body, right foot and surrounding tissue. This 41-year-old male presents to preoperative holding area after keeping himself n.p.o., since mid night for removal of painful retained foreign body in his right foot. The patient works in the Electronics/Robotics field and relates that he stepped on a w... | Orthopedic | Foreign Body Removal - Foot | PREOPERATIVE DIAGNOSIS: , Foreign body, right foot.,POSTOPERATIVE DIAGNOSIS: , Foreign body in the right foot.,PROCEDURE PERFORMED:, Excision of foreign body, right foot and surrounding tissue.,ANESTHESIA: , TIVA and local.,HISTORY:, This 41-year-old male presents to preoperative holding area after keeping himself n.... | orthopedic, foreign body removal, excision of foreign body, ankle tourniquet, plantar aspect, foreign body, foot, ankle, plantar, wound, |
2,223 | Excision of ganglion of the left wrist. A curved incision was made over the presenting ganglion over the dorsal aspect of the wrist. | Orthopedic | Ganglion Excision | PREOPERATIVE DIAGNOSIS: , Ganglion of the left wrist.,POSTOPERATIVE DIAGNOSIS: , Ganglion of the left wrist.,OPERATION: , Excision of ganglion.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Less than 5 mL.,OPERATION: , After a successful anesthetic, the patient was positioned on the operating table. A tourniquet appl... | orthopedic, curved incision, superficial vessels, tourniquet, excision, dorsal, wrist, ganglion |
2,224 | Consultation for left foot pain. | Orthopedic | Foot pain Consultation | CHIEF COMPLAINT:, Left foot pain.,HISTORY:, XYZ is a basketball player for University of Houston who sustained an injury the day prior. They were traveling. He came down on another player's foot sustaining what he describes as an inversion injury. Swelling and pain onset immediately. He was taped but was able to contin... | orthopedic, foot pain, calcaneocuboid joint, dorsal aspect, dorsal talonavicular joint, foot injuries, hindfoot, midfoot, rehab program, walking boot, weightbearing, talonavicular joint, dorsal, talonavicular, ankle, foot, tenderness |
2,225 | Resection of infected bone, left hallux, proximal phalanx, and distal phalanx. Osteomyelitis, left hallux. | Orthopedic | Hallux Infected Bone Resection | PREOPERATIVE DIAGNOSIS: , Osteomyelitis, left hallux.,POSTOPERATIVE DIAGNOSIS: , Osteomyelitis, left hallux.,PROCEDURES PERFORMED: , Resection of infected bone, left hallux, proximal phalanx, and distal phalanx.,ANESTHESIA: , TIVA/Local.,HISTORY:, This 77-year-old male presents to ABCD preoperative holding area after ... | orthopedic, osteomyelitis, proximal phalanx, distal phalanx, infected bone, proximal, bone, phalanx, healing, hallux, infected, tissue, distal, |
2,226 | Cellulitis with associated abscess and foreign body, right foot. Irrigation debridement and removal of foreign body of right foot. Purulent material from the abscess located in the plantar aspect of the foot between the third and fourth metatarsal heads. | Orthopedic | Foreign Body Removal - Foot - 1 | PREOPERATIVE DIAGNOSES:,1. Cellulitis with associated abscess, right foot.,2. Foreign body, right foot.,POSTOPERATIVE DIAGNOSES:,1. Cellulitis with associated abscess, right foot.,2. Foreign body, right foot.,PROCEDURE PERFORMED:,1. Irrigation debridement.,2. Removal of foreign body of right foot.,ANESTHESIA:, S... | orthopedic, removal of foreign body, purulent material, metatarsal, cellulitis, abscess, kerlix, foreign body, foot, irrigation, debridement, purulent, |
2,227 | Flexor carpi radialis and palmaris longus repair. Right wrist laceration with a flexor carpi radialis laceration and palmaris longus laceration 90%, suspected radial artery laceration. | Orthopedic | Flexor Carpi Radialis & Palmaris Longus Repair | PREOPERATIVE DIAGNOSIS:, Right wrist laceration with a flexor carpi radialis laceration and palmaris longus laceration 90%, suspected radial artery laceration.,POSTOPERATIVE DIAGNOSIS:, Right wrist laceration with a flexor carpi radialis laceration and palmaris longus laceration 90%, suspected radial artery laceratio... | orthopedic, kessler stitch, flexor carpi radialis, palmaris longus, radialis, laceration, fiberwire, flexor, carpi, palmaris, longus, repair |
2,228 | Consultation for FCR tendinitis | Orthopedic | FCR tendinitis | HISTORY OF PRESENT PROBLEM:, XYZ was seen by Dr. ABC for an FCR tendinitis. We do not have his reports, but by history she has had two cortisone shots. She plays musical instruments, and it does bother her from time to time. She was considering surgery, but she takes ibuprofen and it seems to be well-controlled. S... | orthopedic, fcr tendinitis, fcr tunnel release, cortisone shot, tendinitis, tunnel release, signs, oriented, shoulder, fcr |
2,229 | Sample Radiology report of knee (growth arrest lines). | Orthopedic | Five views of the right knee. | EXAM: , Five views of the right knee.,HISTORY: , Pain. The patient is status-post surgery, he could not straighten his leg, pain in the back of the knee.,TECHNIQUE:, Five views of the right knee were evaluated. There are no priors for comparison.,FINDINGS: , Five views of the right knee were evaluated and they revea... | orthopedic, fractures dislocations or subluxations, femur and proximal, growth arrest lines, patella alta, fractures, dislocations, subluxations, distal, femur, patella |
2,230 | Endoscopic carpal tunnel release. Left carpal tunnel syndrome. | Orthopedic | Endoscopic Carpal Tunnel Rlease | PREOPERATIVE DIAGNOSIS:, Left carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:, Left carpal tunnel syndrome.,OPERATIONS PERFORMED:, Endoscopic carpal tunnel release.,ANESTHESIA:, I.V. sedation and local (1% Lidocaine).,ESTIMATED BLOOD LOSS:, Zero.,COMPLICATIONS:, None.,PROCEDURE IN DETAIL: , With the patient unde... | orthopedic, fcr, fcu, antebrachial fascia, endoscopic carpal tunnel release, carpal tunnel release, carpal tunnel syndrome, carpal, endoscopic, ligament, tourniquet, transverse, |
2,231 | Left little finger extensor tendon laceration. Repair of left little extensor tendon. | Orthopedic | Extensor Tendon Repair | PREOPERATIVE DIAGNOSIS:, Left little finger extensor tendon laceration.,POSTOPERATIVE DIAGNOSIS: , Left little finger extensor tendon laceration.,PROCEDURE PERFORMED: ,Repair of left little extensor tendon.,COMPLICATIONS:, None.,BLOOD LOSS: , Minimal.,ANESTHESIA: , Bier block.,INDICATIONS: , The patient is a 14-year... | orthopedic, extensor tendon laceration, bier block, pip joint, extensor tendon, tendon, repair, finger, laceration, extensor, |
2,232 | Bilateral C3-C4, C4-C5, C5-C6, and C6-C7 medial facetectomy and foraminotomy with technical difficulty, total laminectomy C3, C4, C5, and C6, excision of scar tissue, and repair of dural tear with Prolene 6-0 and Tisseel. | Orthopedic | Facetectomy & Foraminotomy | PREOPERATIVE DIAGNOSES,1. Neck pain with bilateral upper extremity radiculopathy.,2. Residual stenosis, C3-C4, C4-C5, C5-C6, and C6-C7 with probable instability.,POSTOPERATIVE DIAGNOSES,1. Neck pain with bilateral upper extremity radiculopathy.,2. Residual stenosis, C3-C4, C4-C5, C5-C6, and C6-C7 secondary to facet... | null |
2,233 | Consultation for finger triggering and locking. | Orthopedic | Finger triggering and locking | CHIEF COMPLAINT:, Right middle finger triggering and locking, as well as right index finger soreness at the PIP joint.,HISTORY OF OCCUPATIONAL INJURY OR ILLNESS:, The patient has been followed elsewhere, and we reviewed his records. Essentially, he has had a trigger finger and a mucocyst, and he has had injections. ... | orthopedic, finger triggering, a1 pulley, pip joint, tendinitis, crepitation, locking, mucocyst, synovitis, trigger finger, middle finger triggering, triggering and locking, index finger, finger, triggering, |
2,234 | Endoscopic carpal tunnel release and de Quervain's release. Left carpal tunnel syndrome and de Quervain's tenosynovitis. | Orthopedic | Endoscopic Carpal Tunnel & de Quervain's Release | PREOPERATIVE DIAGNOSIS: ,1. Left carpal tunnel syndrome.,2. de Quervain's tenosynovitis.,POSTOPERATIVE DIAGNOSIS:, ,1. Left carpal tunnel syndrome.,2. de Quervain's tenosynovitis.,OPERATIONS PERFORMED: ,1. Endoscopic carpal tunnel release.,2. de Quervain's release.,ANESTHESIA:, I.V. sedation and local (1% Lid... | orthopedic, de quervain's tenosynovitis, de quervain's release, carpal tunnel syndrome, carpal tunnel release, endoscopic carpal tunnel release, tunnel, transverse, carpal, tourniquet, endoscopic, |
2,235 | Followup 4 months status post percutaneous screw fixation of a right Schatzker IV tibial plateau fracture and second through fifth metatarsal head fractures treated nonoperatively. | Orthopedic | Followup Screw Fixation | REASON FOR VISIT: ,Followup 4 months status post percutaneous screw fixation of a right Schatzker IV tibial plateau fracture and second through fifth metatarsal head fractures treated nonoperatively.,HISTORY OF PRESENT ILLNESS: ,The patient is a 59-year-old gentleman who is now approximately 4 months status post perc... | orthopedic, metatarsal head fractures, tibial plateau fracture, schatzker, percutaneous screw fixation, tibial plateau, metatarsal head, screw fixation, head, screw, fixation, metatarsal |
2,236 | Left elbow manipulation and hardware removal of left elbow. | Orthopedic | Elbow Manipulation | PREOPERATIVE DIAGNOSIS:, Left elbow with retained hardware.,POSTOPERATIVE DIAGNOSIS: , Left elbow with retained hardware.,PROCEDURE: , ,1. Left elbow manipulation.,2. Hardware removal of left elbow.,ANESTHESIA: ,Surgery was performed under general anesthesia.,COMPLICATIONS:, There were no intraoperative complicati... | orthopedic, k-wires, dynasplint, elbow manipulation, hardware removal, retained hardware, elbow, hardware, |
2,237 | Excision of Dupuytren disease of the right hand extending out to the proximal interphalangeal joint of the little finger. The patient is a 51-year-old male with left Dupuytren disease, which is causing contractions both at the metacarpophalangeal and the PIP joint as well as significant discomfort. | Orthopedic | Dupuytren Disease Excision | PREOPERATIVE DIAGNOSIS: , Right hand Dupuytren disease to the little finger.,POSTOPERATIVE DIAGNOSIS: ,Right hand Dupuytren disease to the little finger.,PROCEDURE PERFORMED: ,Excision of Dupuytren disease of the right hand extending out to the proximal interphalangeal joint of the little finger.,COMPLICATIONS: ,Non... | orthopedic, excision of dupuytren disease, proximal interphalangeal joint, dupuytren disease, bier block, pip joint, disease, dupuytren, contractions, metacarpophalangeal, neurovascular, bundles, interphalangeal, finger |
2,238 | Excision dorsal ganglion, right wrist. The extensor retinaculum was then incised and the extensor tendon was dissected and retracted out of the operative field. | Orthopedic | Dorsal Ganglion - Excision | PREOPERATIVE DIAGNOSIS:, Dorsal ganglion, right wrist.,POSTOPERATIVE DIAGNOSIS:, Dorsal ganglion, right wrist.,OPERATIONS PERFORMED:, Excision dorsal ganglion, right wrist.,ANESTHESIA:, Monitored anesthesia care with regional anesthesia applied by surgeon.,TOURNIQUET TIME:, minutes.,DESCRIPTION OF PROCEDURE: , Wit... | orthopedic, excision dorsal ganglion, extensor tendon, extensor retinaculum, dorsal ganglion, retinaculum, ganglion |
2,239 | Left elbow pain. Fracture of the humerus, spiral. Possible nerve injuries to the radial and median nerve, possibly neurapraxia. | Orthopedic | Elbow Pain - Consult | CHIEF COMPLAINT: , Left elbow pain.,HISTORY OF PRESENT ILLNESS: ,This 17-year-old male was fighting with some other kids in Juvenile Hall when he felt some pain in his left elbow, causing sudden pain. He also has pain in his left ankle, but he is able to walk normally. He has had previous pain in his left knee. He ... | |
2,240 | A 47-year-old female with a posttraumatic AV in the right femoral head. | Orthopedic | Discharge Summary - Hip Surgery | ADMITTING DIAGNOSIS:, Posttraumatic AV in right femoral head.,DISCHARGE DIAGNOSIS:, Posttraumatic AV in right femoral head.,SECONDARY DIAGNOSES PRIOR TO HOSPITALIZATION:,1. Opioid use.,2. Right hip surgery.,3. Appendectomy.,4. Gastroesophageal reflux disease.,5. Hepatitis diagnosed by liver biopsy.,6. Blood tra... | null |
2,241 | Anterior cervical discectomy, osteophytectomy, foraminotomies, spinal cord decompression, fusion with machined allografts, Eagle titanium plate, Jackson-Pratt drain placement, and intraoperative monitoring with EMGs and SSEPs | Orthopedic | Discectomy, Osteophytectomy, & Foraminotomy | PREOPERATIVE DIAGNOSES:, Cervical degenerative disc disease, spondylosis, severe myelopathy, spinal cord compression especially at C3-C4, C4-C5, and C5-C6, and progressive quadriparesis.,POSTOPERATIVE DIAGNOSES:, Cervical degenerative disc disease, spondylosis, severe myelopathy, spinal cord compression especially at... | null |
2,242 | Stenosing tenosynovitis first dorsal extensor compartment/de Quervain tendonitis. Release of first dorsal extensor compartment. | Orthopedic | Dorsal Extensor Compartment Release | PREOPERATIVE DIAGNOSIS: , Stenosing tenosynovitis first dorsal extensor compartment/de Quervain tendonitis.,POSTOPERATIVE DIAGNOSIS: , Stenosing tenosynovitis first dorsal extensor compartment/de Quervain tendonitis.,PROCEDURE PERFORMED:, Release of first dorsal extensor compartment.,ASSISTANT: , None.,ANESTHESIA: , B... | orthopedic, dorsal extensor compartment, de quervain tendonitis, dorsal, extensor, quervain, tendonitis, retinaculum, tenosynovitis, tourniquet, |
2,243 | Trauma/ATV accident resulting in left open humerus fracture. | Orthopedic | Discharge Summary - ATV Accident | ADMITTING DIAGNOSIS: , Trauma/ATV accident resulting in left open humerus fracture.,DISCHARGE DIAGNOSIS:, Trauma/ATV accident resulting in left open humerus fracture.,SECONDARY DIAGNOSIS:, None.,HISTORY OF PRESENT ILLNESS: , For complete details, please see dictated history and physical by Dr. X dated July 23, 2008. ... | orthopedic, humerus fracture, trauma, irrigation and debridement, atv accident, upper extremity, humerus, fracture, |
2,244 | Bilateral L5 dorsal ramus block and bilateral S1, S2, and S3 lateral branch block for sacroiliac joint pain. Fluoroscopic pillar view was used to identify the bony landmarks of the sacrum and sacroiliac joint and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were ... | Orthopedic | Dorsal Ramus & Branch Block | PROCEDURE: , Bilateral L5 dorsal ramus block and bilateral S1, S2, and S3 lateral branch block.,INDICATION: , Sacroiliac joint pain.,INFORMED CONSENT: , The risks, benefits and alternatives of the procedure were discussed with the patient. The patient was given opportunity to ask questions regarding the procedure, its... | orthopedic, sacroiliac, lateral branch block, ramus block, branch block, sacroiliac joint, dorsal ramus, fluoroscopic, branch, dorsal, ramus, bilateral, needle, block, |
2,245 | Redo L4-5 diskectomy, left - recurrent herniation L4-5 disk with left radiculopathy. | Orthopedic | Diskectomy | PREOPERATIVE DIAGNOSIS (ES):, Recurrent herniation L4-5 disk with left radiculopathy.,POSTOPERATIVE DIAGNOSIS (ES):, Recurrent herniation L4-5 disk with left radiculopathy.,PROCEDURE:, Redo L4-5 diskectomy left.,COMPLICATIONS:, None.,ANTIBIOTIC (S),: Vancomycin given preoperatively.,ANESTHESIA:, General endotracheal.,E... | orthopedic, herniation, andrews frame, csf leakage, depo-medrol, l4-5, proxi-strips, diskectomy, endotracheal anesthesia, lumbosacral fascia, modified knee-chest position, radiculopathy, supine position, nerve root, duraprep, |
2,246 | Decompressive laminectomy at T12 with bilateral facetectomies, decompression of T11 and T12 nerve roots bilaterally with posterolateral fusion supplemented with allograft bone chips and pedicle screws and rods with crosslink Synthes ClickX System. | Orthopedic | Decompressive Laminectomy | PREOPERATIVE DIAGNOSIS: , T12 compression fracture with cauda equina syndrome and spinal cord compression.,POSTOPERATIVE DIAGNOSIS:, T12 compression fracture with cauda equina syndrome and spinal cord compression.,OPERATION PERFORMED: , Decompressive laminectomy at T12 with bilateral facetectomies, decompression of T1... | orthopedic, facetectomies, decompression, posterolateral fusion, synthes click'x system, decompressive laminectomy, leksell rongeur, kerrison rongeur, transverse processes, thecal sac, nerve roots, pedicle screws, spinous process, pedicle, process, screws, rods, laminectomy, decompressive, spinous, |
2,247 | Wrist de Quervain stenosing tenosynovitis. de Quervain release. Fascial lengthening flap of the 1st dorsal compartment. | Orthopedic | de Quervain Release - Wrist | PREOPERATIVE DIAGNOSIS:, Wrist de Quervain stenosing tenosynovitis.,POSTOPERATIVE DIAGNOSIS: , Wrist de Quervain stenosing tenosynovitis.,TITLE OF PROCEDURES,1. de Quervain release.,2. Fascial lengthening flap of the 1st dorsal compartment.,ANESTHESIA:, MAC.,COMPLICATIONS: , None.,PROCEDURE IN DETAIL: , After MAC an... | orthopedic, de quervain, tenosynovitis, de quervain release, fascial lengthening flap, dorsal compartment, sheath, wrist, dorsal, tourniquet, |
2,248 | Degenerative disk disease at L4-L5 and L5-S1. Anterior exposure diskectomy and fusion at L4-L5 and L5-S1. | Orthopedic | Diskectomy & Fusion | PREOPERATIVE DIAGNOSIS: , Degenerative disk disease at L4-L5 and L5-S1.,POSTOPERATIVE DIAGNOSIS:, Degenerative disk disease at L4-L5 and L5-S1.,PROCEDURE PERFORMED: ,Anterior exposure diskectomy and fusion at L4-L5 and L5-S1.,ANESTHESIA: , General.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS: , 150 mL.,PROCEDURE IN D... | orthopedic, anterior exposure, degenerative disk disease, disk disease, disk space, diskectomy, fusion, |
2,249 | Delayed open reduction internal fixation with plates and screws, 6-hole contoured distal fibular plate and screws reducing posterolateral malleolar fragment as well as medial malleolar fragment. | Orthopedic | Delayed ORIF | PREOPERATIVE DIAGNOSES:,1. Right ankle trimalleolar fracture.,2. Right distal tibia plafond fracture with comminuted posterolateral impacted fragment.,OPERATIVE PROCEDURE: ,Delayed open reduction internal fixation with plates and screws, 6-hole contoured distal fibular plate and screws reducing posterolateral malleo... | null |
2,250 | Torn rotator cuff and subacromial spur with impingement syndrome, right shoulder. Diagnostic arthroscopy with subacromial decompression and open repair of rotator cuff using three Panalok suture anchors. | Orthopedic | Diagnostic Arthroscopy | PREOPERATIVE DIAGNOSIS:, Torn rotator cuff, right shoulder.,POSTOPERATIVE DIAGNOSES:,1. Torn rotator cuff, right shoulder.,2. Subacromial spur with impingement syndrome, right shoulder.,PROCEDURE PERFORMED:,1. Diagnostic arthroscopy with subacromial decompression.,2. Open repair of rotator cuff using three Panalok... | orthopedic, subacromial decompression, panalok suture, repair of rotator cuff, torn rotator cuff, diagnostic arthroscopy, subacromial space, subacromial spur, arthroscopy, panalok, shoulder, subacromial, |
2,251 | Incision and drainage with extensive debridement, left shoulder. Removal total shoulder arthroplasty (uncemented humeral Biomet component; cemented glenoid component). Implantation of antibiotic beads, left shoulder. | Orthopedic | Debridement - Shoulder | TITLE OF OPERATION: ,1. Incision and drainage with extensive debridement, left shoulder.,2. Removal total shoulder arthroplasty (uncemented humeral Biomet component; cemented glenoid component).,3. Implantation of antibiotic beads, left shoulder.,INDICATION FOR SURGERY: , The patient was seen multiple times preoper... | orthopedic, incision and drainage, shoulder arthroplasty, extensive debridement, uncemented humeral, biomet, cemented, antibiotic beads, biceps tenosynovitis, rotator cuff tear, total shoulder arthroplasty, proximal humerus, vicryl sutures, glenoid, tendon, proximal, humerus, beads, shoulder, incision, |
2,252 | Carpal tunnel syndrome and de Quervain's stenosing tenosynovitis. Carpal tunnel release and de Quervain's release. A longitudinal incision was made in line with the 4th ray, from Kaplan's cardinal line proximally to 1 cm distal to the volar wrist crease. The dissection was carried down to the superficial aponeurosi... | Orthopedic | de Quervain Release - Carpal | PREOPERATIVE DIAGNOSIS,1. Carpal tunnel syndrome.,2. de Quervain's stenosing tenosynovitis.,POSTOPERATIVE DIAGNOSIS,1. Carpal tunnel syndrome.,2. de Quervain's stenosing tenosynovitis.,TITLE OF PROCEDURE,1. Carpal tunnel release.,2. de Quervain's release.,ANESTHESIA: , MAC,COMPLICATIONS: , None.,PROCEDURE IN DETAIL:... | orthopedic, de quervain's release, carpal tunnel syndrome, tenosynovitis, carpal, incision, aponeurosis, tunnel, cut, |
2,253 | CT REPORT - Soft Tissue Neck | Orthopedic | CT Neck - 1 | FINDINGS:,There is a lobulated mass lesion of the epiglottis measuring approximately 22 x 16 x 30 mm (mediolateral x AP x craniocaudal) in size. There is slightly greater involvement on the right side however there is bilateral involvement of the aryepiglottic folds. There is marked enlargement of the bilateral aryepig... | orthopedic, deep cervical node, epiglottic mass, epiglottic space, aryepiglottic folds, jugulodigastric nodes, level deep, cervical node, deep cervical, node, jugulodigastric, aryepiglottic, deep, cervical |
2,254 | Noncontrast CT scan of the lumbar spine. Left lower extremity muscle spasm. Transaxial thin slice CT images of the lumbar spine were obtained with sagittal and coronal reconstructions on emergency basis, as requested. | Orthopedic | CT Lumbar Spine | EXAM:, Noncontrast CT scan of the lumbar spine,REASON FOR EXAM: , Left lower extremity muscle spasm.,COMPARISONS: , None.,FINDINGS: , Transaxial thin slice CT images of the lumbar spine were obtained with sagittal and coronal reconstructions on emergency basis, as requested.,No abnormal paraspinal masses are identifie... | orthopedic, noncontrast ct scan, lower extremity muscle spasm, neural foraminal stenosis, lumbar spine, spine, disk, lumbar, ct, intervertebral, canal, foraminal, noncontrast, stenosis, |
2,255 | CT of Lumbar Spine without Contrast. Patient with history of back pain after a fall. | Orthopedic | CT of Lumbar Spine w/o Contrast | EXAM: , Lumbar spine CT without contrast.,HISTORY: , Back pain after a fall.,TECHNIQUE:, Noncontrast axial images were acquired through the lumbar spine. Coronal and sagittal reconstruction views were also obtained.,FINDINGS: , There is no evidence for acute fracture or subluxation. There is no spondylolysis or spond... | orthopedic, lumbar spine, back pain, ct, coronal, atherosclerotic, axial images, central canal, compression, deformity, degenerative, disk space, fracture, intervertebral, neuroforamen, sagittal, spondylolisthesis, spondylolysis, subluxation, wedge, without contrast, contrast, spine, lumbar, noncontrast, |
2,256 | This is a middle-aged female with low back pain radiating down the left leg and foot for one and a half years. | Orthopedic | CT Lumbar Spine - 1 | FINDINGS:,High resolution computerized tomography was performed from T12-L1 to the S1 level with reformatted images in the sagittal and coronal planes and 3D reconstructions performed. COMPARISON: Previous MRI examination 10/13/2004.,There is minimal curvature of the lumbar spine convex to the left.,T12-L1, L1-2, L2-3:... | orthopedic, posterior annular disc, circumferential annular disc, normal central canal, annular disc bulging, lumbar spine, posterior annular, facet joints, annular disc, disc bulging, tomography, disc, lumbar, postsurgical, spine, annular, bulging, |
2,257 | This is a middle-aged female with two month history of low back pain and leg pain. | Orthopedic | CT Lumbar Spine - 2 | FINDINGS:,Axial scans were performed from L1 to S2 and reformatted images were obtained in the sagittal and coronal planes.,Preliminary scout film demonstrates anterior end plate spondylosis at T11-12 and T12-L1.,L1-2: There is normal disc height, anterior end plate spondylosis, very minimal vacuum change with no poste... | orthopedic, anterior end plate spondylosis, compressive right neural foraminal, compressive annular disc bulging, anterior end plate, annular disc bulging, normal central canal, plate spondylosis, central canal, vacuum change, disc bulging, neural foraminal, facet arthrosis, anterior, spondylosis, neural, lumbar, disc,... |
2,258 | CT REPORT - Soft Tissue Neck | Orthopedic | CT Neck - 2 | FINDINGS:,There is a well demarcated mass lesion of the deep lobe of the left parotid gland measuring approximately 2.4 X 3.9 X 3.0cm (AP X transverse X craniocaudal) in size. The lesion is well demarcated. There is a solid peripheral rim with a mean attenuation coefficient of 56.3. There is a central cystic appearing ... | orthopedic, cervical nodal, mass lesion, deep lobe, deep lateral, lateral cervical, parotid gland, cervical, lesion, gland, parotid, deep |
2,259 | Motor vehicle collision. CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast. | Orthopedic | CT Head, Facial Bones, Cervical Spine - 1 | CT HEAD WITHOUT CONTRAST, CT FACIAL BONES WITHOUT CONTRAST, AND CT CERVICAL SPINE WITHOUT CONTRAST,REASON FOR EXAM: , Motor vehicle collision.,CT HEAD,TECHNIQUE: , Noncontrast axial CT images of the head were obtained without contrast.,FINDINGS: , There is no acute intracranial hemorrhage, mass effect, midline shift, o... | orthopedic, intracranial disease, motor vehicle collision, orbital nerves, extra-ocular muscles, cervical spine, ct cervical spine, ct facial bones, ct head, axial ct images, facial bone fracture, facial bones, ct, noncontrast, intracranial, axial, spine, fracture, cervical, contrast, facial, bones, |
2,260 | Common CT C-Spine template | Orthopedic | CT C-Spine | TECHNIQUE: , Sequential axial CT images were obtained through the cervical spine without contrast. Additional high resolution coronal and sagittal reconstructed images were also obtained for better visualization of the osseous structures. ,FINDINGS: , The cervical spine demonstrates normal alignment and mineralizatio... | orthopedic, sequential axial ct images, atlanto-dens interval, dens, ct c spine, cervical spineNOTE |
2,261 | Motor vehicle collision. CT head without contrast and CT cervical spine without contrast. Noncontrast axial CT images of the head were obtained. | Orthopedic | CT Head and C Spine | CT HEAD WITHOUT CONTRAST AND CT CERVICAL SPINE WITHOUT CONTRAST,REASON FOR EXAM: , Motor vehicle collision.,CT HEAD WITHOUT CONTRAST,TECHNIQUE:, Noncontrast axial CT images of the head were obtained.,FINDINGS: , There is no acute intracranial hemorrhage, mass effect, midline shift, or extra-axial fluid collection. Th... | orthopedic, muscle spasms, cervical lordosis, intracranial hemorrhage, motor vehicle collision, axial ct images, ct head, ct, anterior, cyst, polyp, maxillary, contrast, intracranial, sinuses, spine, axial, head, cervical, noncontrast |
2,262 | CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast. | Orthopedic | CT Head, Facial Bones, Cervical Spine | EXAM: , CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast.,REASON FOR EXAM:, A 68-year-old status post fall with multifocal pain.,COMPARISONS: , None.,TECHNIQUE: , Sequential axial CT images were obtained from the vertex to the thoracic inlet without contrast. Addition... | orthopedic, sagittal, coronal, soft tissue swelling, paranasal sinuses, mastoid air, acute fracture, maxillary sinuses, tissue swelling, underlying fracture, multilevel degenerative, ct head, soft tissue, facial bones, cervical spine, ct, facial, bones, spine, cervical |
2,263 | The patient has been suffering from intractable back and leg pain. | Orthopedic | Consult - Back & Leg Pain | Her axial back pain is greatly improved, but not completely eradicated. There is absolutely no surgery at this point in time that would be beneficial for her axial back pain due to her lumbar internal disc disruption.,PAST MEDICAL HISTORY:, Significant for anxiety disorder.,PAST SURGICAL HISTORY: , Foot surgery, abdo... | orthopedic, multilevel lumbar internal disc disruption, denervation procedure, lumbar facet joint syndrome, swing a golf, lumbar internal disc, internal disc disruption, lumbar internal, internal disc, disc disruption, intractable, surgery, disc, lumbar |
2,264 | Lateral and plantar condylectomy, fifth left metatarsal. | Orthopedic | Condylectomy | TITLE OF OPERATION:, Lateral and plantar condylectomy, fifth left metatarsal.,PREOPERATIVE DIAGNOSIS: , Prominent, lateral, and plantar condyle hypertrophy, fifth left metatarsal.,POSTOPERATIVE DIAGNOSIS: , Prominent, lateral, and plantar condyle hypertrophy, fifth left metatarsal.,ANESTHESIA: ,Monitored anesthesia c... | orthopedic, plantar condyle hypertrophy, condyle hypertrophy, subcutaneous tissues, ankle tourniquet, metatarsophalangeal joint, metatarsal head, plantar condylectomy, tourniquet, condylectomy, plantar, ankle, metatarsal, |
2,265 | Closed reduction percutaneous pinning, left distal humerus. Closed type-III supracondylar fracture, left distal humerus. Tethered brachial artery, left elbow. | Orthopedic | Closed Reduction Percutaneous Pinning | PREOPERATIVE DIAGNOSIS: , Closed type-III supracondylar fracture, left distal humerus.,POSTOPERATIVE DIAGNOSES:,1. Closed type-III supracondylar fracture, left distal humerus.,2. Tethered brachial artery, left elbow.,PROCEDURE PERFORMED: , Closed reduction percutaneous pinning, left distal humerus.,SPECIFICATIONS: , ... | orthopedic, closed reduction, percutaneous pinning, distal humeru, supracondylar fracture, tethered brachial artery, artery, supracondylar, brachial, pinning, reduction, fracture, humerus, elbow, |
2,266 | Patient with complaint of left knee pain. Patient is obese and will be starting Medifast Diet. | Orthopedic | Consult - Knee Pain | CHIEF COMPLAINT:, Left knee pain.,SUBJECTIVE: , This is a 36-year-old white female who presents to the office today with a complaint of left knee pain. She is approximately five days after a third Synvisc injection. She states that the knee is 35% to 40 % better, but continues to have a constant pinching pain when s... | orthopedic, medifast, medifast diet, obesity, gastric bypass, knee pain, weight reduction, knee, |
2,267 | Axial images through the cervical spine with coronal and sagittal reconstructions. | Orthopedic | CT C-Spine - 1 | EXAM: , CT cervical spine.,REASON FOR EXAM: , MVA, feeling sleepy, headache, shoulder and rib pain.,TECHNIQUE:, Axial images through the cervical spine with coronal and sagittal reconstructions.,FINDINGS:, There is reversal of the normal cervical curvature at the vertebral body heights. The intervertebral disk space... | orthopedic, c-spine, axial images, sagittal reconstructions, cervical spine, sagittal, fracture, coronal, spine, axial, cervical, ct, |
2,268 | CT cervical spine for trauma. CT examination of the cervical spine was performed without contrast. Coronal and sagittal reformats were obtained for better anatomical localization. | Orthopedic | CT C-Spine - 2 | EXAM:, CT cervical spine (C-spine) for trauma.,FINDINGS:, CT examination of the cervical spine was performed without contrast. Coronal and sagittal reformats were obtained for better anatomical localization. Cervical vertebral body height, alignment and interspacing are maintained. There is no evidence of fracture... | orthopedic, c-spine, anatomical, degenerative endplate, ct examination, cervical spine, coronal, ct, spine, cervicalNOTE |
2,269 | Trimalleolar ankle fracture and dislocation right ankle. A comminuted fracture involving the lateral malleolus, as well as a medial and posterior malleolus fracture as well. Closed open reduction and internal fixation of right ankle. | Orthopedic | Closed ORIF - Ankle | PREOPERATIVE DIAGNOSES:,1. Trimalleolar ankle fracture.,2. Dislocation right ankle.,POSTOPERATIVE DIAGNOSES:,1. Trimalleolar ankle fracture.,2. Dislocation right ankle.,PROCEDURE PERFORMED: , Closed open reduction and internal fixation of right ankle.,ANESTHESIA: ,Spinal with sedation.,COMPLICATIONS: ,None.,ESTIM... | orthopedic, ankle fracture, dislocation, open reduction, internal fixation, orif, trimalleolar ankle fracture, cortical screw, cancellous screws, fracture site, fracture, ankle, malleolus, |
2,270 | Right distal both-bone forearm fracture. Closed reduction under conscious sedation and application of a splint was warranted. | Orthopedic | Closed Reduction - 1 | PREOPERATIVE DIAGNOSIS: , Right distal both-bone forearm fracture.,POSTOPERATIVE DIAGNOSIS: , Right distal both-bone forearm fracture.,INDICATIONS:, Mr. ABC is a 10-year-old boy who suffered a fall resulting in a right distal both-bone forearm fracture. Upon evaluation by Orthopedic Surgery team in the emergency depa... | orthopedic, closed reduction, distal both bone forearm, emergency department, pollicis longus, bone forearm, forearm fracture, conscious sedation, emergency, department, pollicis, longus, splint, distal, bone, forearm, conscious, sedation, fracture, reduction, |
2,271 | Postoperative followup note - Cervicalgia, cervical radiculopathy, and difficulty swallowing status post cervical fusion C3 through C7 with lifting of the plate. | Orthopedic | Cervicalgia | FAMILY HISTORY: , Her father died at the age of 80 from prostate cancer. Her mother died at the age of 67. She did abuse alcohol. She had a brother died at the age of 70 from bone and throat cancer. She has two sons, ages 37 and 38 years old who are healthy. She has two daughters, ages 60 and 58 years old, both wi... | orthopedic, c3 through c7, pain scale, mris, x-rays, cervical discectomy and fusion, cervical radiculopathy, cervical fusion, cervical discectomy, cervical plate, difficulty swallowing, cranial nerves, radiculopathy, discectomy, cervicalgia, postoperative, fusion, swallowing, |
2,272 | Closing wedge osteotomy, fifth metatarsal with internal screw fixation, right foot. | Orthopedic | Closing Wedge Osteotomy | PREOPERATIVE DIAGNOSIS: , Tailor's bunion, right foot.,POSTOPERATIVE DIAGNOSIS: , Tailor's bunion, right foot.,PROCEDURE: , Closing wedge osteotomy, fifth metatarsal with internal screw fixation, right foot.,ANESTHESIA: , Local infiltrate with IV sedation.,INDICATIONS FOR SURGERY: , The patient has had a longstanding h... | orthopedic, internal screw fixation, osteotomy, closing wedge osteotomy, tailor's bunion, screw fixation, periosteal layer, metatarsal head, wedge osteotomy, metatarsal, anesthesia |
2,273 | Left hip cemented hemiarthroplasty and biopsy of the tissue from the fracture site and resected femoral head sent to the pathology for further assessment. | Orthopedic | Cemented Hemiarthroplasty & Biopsy | PREOPERATIVE DIAGNOSIS:, Closed displaced probable pathological fracture, basicervical femoral neck, left hip.,POSTOPERATIVE DIAGNOSIS: , Closed displaced probable pathological fracture, basicervical femoral neck, left hip.,PROCEDURES PERFORMED:,1. Left hip cemented hemiarthroplasty.,2. Biopsy of the tissue from the... | null |
2,274 | Cervical spondylosis and kyphotic deformity. She had a nerve conduction study and a diagnosis of radiculopathy was made. She had an MRI of lumbosacral spine, which was within normal limits. She then developed a tingling sensation in the right middle toe. | Orthopedic | Cervical Spondylosis - Neuro Consult | REASON FOR NEUROLOGICAL CONSULTATION: , Cervical spondylosis and kyphotic deformity. The patient was seen in conjunction with medical resident Dr. X. I personally obtained the history, performed examination, and generated the impression and plan.,HISTORY OF PRESENT ILLNESS: ,The patient is a 45-year-old African-Americ... | orthopedic, kyphotic, cervical, radiculopathy, myelopathy, kyphotic deformity, cord compression, cervical spondylosis, toe, spondylosis, cord, |
2,275 | Left distal both-bone forearm fracture. Closed reduction with splint application with use of image intensifier. | Orthopedic | Closed Reduction - 2 | PREOPERATIVE DIAGNOSIS: , Left distal both-bone forearm fracture.,POSTOPERATIVE DIAGNOSIS: , Left distal both-bone forearm fracture.,PROCEDURE:, Closed reduction with splint application with use of image intensifier.,INDICATIONS: , Mr. ABC is an 11-year-old boy who sustained a fall on 07/26/2008. Evaluation in the em... | orthopedic, closed reduction, reduction with splint application, distal both bone forearm, distal both bone, splint application, emergency department, conscious sedation, image intensifier, bone forearm, forearm fracture, reduction, emergency, department, conscious, displacement, splint, sedation, tong, distal, bone, i... |
2,276 | Carpal tunnel syndrome. Endoscopic carpal tunnel release. After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion, the arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg. | Orthopedic | Carpal Tunnel Release - Endoscopic | PREOPERATIVE DIAGNOSIS:, Carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Carpal tunnel syndrome.,TITLE OF PROCEDURE: , Endoscopic carpal tunnel release.,ANESTHESIA: , MAC,PROCEDURE: , After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fas... | orthopedic, endoscopic, carpal tunnel syndrome, carpal tunnel release, carpal ligament, tourniquet, carpal, esmarch, tunnel, transverse, ligament |
2,277 | Left knee arthroscopy with removal of the cartilage loose body and microfracture of the medial femoral condyle with chondroplasty. | Orthopedic | Cartilage Loose Body Removal | PREOPERATIVE DIAGNOSIS: , Left knee medial femoral condyle osteochondritis dissecans.,POSTOPERATIVE DIAGNOSIS: , Left knee medial femoral condyle osteochondritis dissecans.,PROCEDURES:, Left knee arthroscopy with removal of the cartilage loose body and microfracture of the medial femoral condyle with chondroplasty.,AN... | orthopedic, knee arthroscopy, chondroplasty, medial femoral condyle, cartilage loose body, loose cartilage, knee, arthroscopy, tourniquet, microfracture, femoral, cartilage, |
2,278 | Carpal tunnel syndrome. Open carpal tunnel release. A longitudinal incision was made in line with the 4th ray. The dissection was carried down to the superficial aponeurosis, which was cut. The distal edge of the transverse carpal ligament was identified with a hemostat. | Orthopedic | Carpal Tunnel Release - Open | PREOPERATIVE DIAGNOSIS: , Carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Carpal tunnel syndrome.,TITLE OF PROCEDURE: ,Open carpal tunnel release.,COMPLICATIONS: ,None.,PROCEDURE IN DETAIL: ,After administering appropriate antibiotics and general anesthesia the Left upper extremity was prepped and draped in the u... | orthopedic, carpal ligament, carpal tunnel release, carpal tunnel syndrome, transverse carpal ligament, transverse, ligament, hemostat, tunnel, incision |
2,279 | Followup cervical spinal stenosis. Her symptoms of right greater than left upper extremity pain, weakness, paresthesias had been worsening after an incident when she thought she had exacerbated her conditions while lifting several objects. | Orthopedic | Cervical Spinal Stenosis | REASON FOR VISIT: ,Followup cervical spinal stenosis.,HISTORY OF PRESENT ILLNESS: ,Ms. ABC returns today for followup regarding her cervical spinal stenosis. I have last seen her on 06/19/07. Her symptoms of right greater than left upper extremity pain, weakness, paresthesias had been worsening after an incident on... | null |
2,280 | Left total knee cemented arthroplasty. Severe tricompartmental osteoarthritis, left knee with varus deformity. | Orthopedic | Cemented Arthroplasty | PREOPERATIVE DIAGNOSIS: , Severe tricompartmental osteoarthritis, left knee with varus deformity.,POSTOPERATIVE DIAGNOSIS:, Severe tricompartmental osteoarthritis, left knee with varus deformity.,PROCEDURE PERFORMED: ,Left total knee cemented arthroplasty.,ANESTHESIA: , Spinal with Duramorph.,ESTIMATED BLOOD LOSS: ,... | null |
2,281 | Right carpal tunnel release. Right carpal tunnel syndrome. This is a 54-year-old female who was complaining of right hand numbness and tingling of the median distribution and has elected to undergo carpal tunnel surgery secondary to failure of conservative management. | Orthopedic | Carpal Tunnel Release - 9 | PREOPERATIVE DIAGNOSIS:, Right carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:, Right carpal tunnel syndrome.,PROCEDURE:, Right carpal tunnel release.,ANESTHESIA:, Bier block to the right hand.,TOTAL TOURNIQUET TIME: , 20 minutes.,COMPLICATIONS: , None.,DISPOSITION: , Stable to PACU.,ESTIMATED BLOOD LOSS: , Less th... | orthopedic, carpal tunnel release, carpal tunnel syndrome, median nerve, bier block, carpal ligament, tunnel, carpal, transverse, median, |
2,282 | Left carpal tunnel release. Left carpal tunnel syndrome. Severe compression of the median nerve on the left at the wrist. | Orthopedic | Carpal Tunnel Release - 6 | PREOPERATIVE DIAGNOSIS: , Left carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:, Left carpal tunnel syndrome.,OPERATIVE PROCEDURE PERFORMED:, Left carpal tunnel release.,FINDINGS:, Showed severe compression of the median nerve on the left at the wrist.,SPECIMENS: ,None.,FLUIDS:, 500 mL of crystalloids.,URINE OUTPU... | orthopedic, compression, wrist, carpal tunnel release, carpal tunnel syndrome, median nerve, tunnel, carpal, |
2,283 | Right carpal tunnel syndrome. Right carpal tunnel release. | Orthopedic | Carpal Tunnel Release - 7 | PREOPERATIVE DIAGNOSIS: , Right carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:, Right carpal tunnel syndrome.,PROCEDURE PERFORMED: , Right carpal tunnel release.,PROCEDURE NOTE: ,The right upper extremity was prepped and draped in the usual fashion. IV sedation was supplied by the anesthesiologist. A local block ... | orthopedic, superficial palmar arch, carpal tunnel release, carpal tunnel syndrome, transverse wrist crease, superficial, ligament, |
2,284 | Right carpal tunnel release and right index and middle fingers release A1 pulley. Right carpal tunnel syndrome and right index finger and middle fingers tenosynovitis. | Orthopedic | Carpal Tunnel Release - 8 | PREOPERATIVE DIAGNOSES:,1. Right carpal tunnel syndrome.,2. Right index finger and middle fingers tenosynovitis.,POSTOPERATIVE DIAGNOSES:,1. Right carpal tunnel syndrome.,2. Right index finger and middle fingers tenosynovitis.,PROCEDURES PERFORMED:,1. Right carpal tunnel release.,2. Right index and middle fingers... | orthopedic, compressed median nerve, stenosing tenosynovitis, carpal tunnel release, carpal tunnel syndrome, middle fingers, carpal tunnel, littler scissors, median nerve, copious irrigation, volar aspect, tunnel, pulley, carpal, fingers, index, tourniquet, ligament, tenosynovitis, superficialis, tendons, |
2,285 | Bilateral open carpal tunnel release. | Orthopedic | Carpal Tunnel Release - 5 | PREOPERATIVE DIAGNOSIS: ,Carpal tunnel syndrome, bilateral.,POSTOPERATIVE DIAGNOSIS: , Carpal tunnel syndrome, bilateral.,ANESTHESIA:, General,NAME OF OPERATION: , Bilateral open carpal tunnel release.,FINDINGS AT OPERATION: , The patient had identical, very thick, transverse carpal ligaments, with dull synovium.,PRO... | orthopedic, bilateral open carpal tunnel, carpal tunnel syndrome, carpal tunnel release, carpal tunnel, release, tourniquet, bilateral, tunnel, carpal |
2,286 | Left endoscopic carpal tunnel release and endotracheal fasciotomy. | Orthopedic | Carpal Tunnel Release - 2 | PREOPERATIVE DIAGNOSIS: , Left carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Left carpal tunnel syndrome.,OPERATIVE PROCEDURE:,1. Left endoscopic carpal tunnel release.,2. Endotracheal fasciotomy.,ANESTHESIA:, General.,COMPLICATIONS: , None.,INDICATION: , The patient is a 62-year-old lady with the aforementione... | orthopedic, carpal tunnel syndrome, antebrachial fascia, antebrachial fasciotomy, carpal tunnel release, electrocautery, fasciotomy, hamate, wrist crease, endoscopic carpal tunnel release, transverse carpal ligament, carpal tunnel, transverse carpal, carpal ligament, carpal, antebrachial, transverse, ligament |
2,287 | Right open carpal tunnel release and cortisone injection, left carpal tunnel. | Orthopedic | Carpal Tunnel Release - 4 | PREOPERATIVE DIAGNOSIS: ,Bilateral carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Bilateral carpal tunnel syndrome.,PROCEDURES:,1. Right open carpal tunnel release.,2. Cortisone injection, left carpal tunnel.,ANESTHESIA: , General LMA.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS:, None.,INDICATIONS:, This p... | orthopedic, carpal tunnel syndrome, 4 x 4s, adaptic, carpal canal, coban, cortisone injection, esmarch, kling, metzenbaum, carpal tunnel release, electrocautery, fibrous band, palmar fascia, tourniquet, transverse carpal ligament, bilateral carpal tunnel, baby metzenbaum scissors, carpal ligament, bilateral carpal, met... |
2,288 | Right carpal tunnel release. | Orthopedic | Carpal Tunnel Release - 1 | PREOPERATIVE DIAGNOSIS: , Right carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Right carpal tunnel syndrome.,TITLE OF THE PROCEDURE: , Right carpal tunnel release.,COMPLICATIONS:, There were no complications during the procedure.,SPECIMEN: ,The specimen was sent to pathology.,INSTRUMENTS: , All counts were correc... | orthopedic, carpal tunnel syndrome, ace wrap, emg, freer elevator, kerlix, weitlaner retractor, bulky dressing, carpal tunnel, carpal tunnel release, palmar fascia, subcutaneous fat, lidocaine with epinephrine, transverse carpal ligament, carpal ligament, carpal, tunnel, ligament, |
2,289 | Carpal tunnel release with transverse carpal ligament reconstruction. A longitudinal incision was made in line with the fourth ray, from Kaplan's cardinal line proximally to 1 cm distal to the volar wrist crease. The dissection was carried down to the superficial aponeurosis. | Orthopedic | Carpal Ligament Reconstruction | PROCEDURE:, Carpal tunnel release with transverse carpal ligament reconstruction.,PROCEDURE IN DETAIL: , After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion. The arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 ... | orthopedic, carpal tunnel, carpal ligament reconstruction, transverse carpal ligament, ulnar, hemostat, transverse, superficial, ligament, carpal |
2,290 | Endoscopic release of left transverse carpal ligament. | Orthopedic | Carpal Ligament Release - 1 | PREOPERATIVE DIAGNOSIS:, Carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:, Carpal tunnel syndrome.,PROCEDURE: , Endoscopic release of left transverse carpal ligament.,ANESTHESIA:, Monitored anesthesia care with regional anesthesia provided by surgeon. ,TOURNIQUET TIME: , 12 minutes.,OPERATIVE PROCEDURE IN DETAIL: ,... | orthopedic, carpal tunnel syndrome, antebrachial fascia, carpal, ligament, palmar, synovium, tourniquet, transverse carpal ligament, transverse incision, agee inside job, transverse carpal, carpal ligament, carpal tunnel, antebrachial, release, endoscopic, |
2,291 | Left carpal tunnel release, left ulnar nerve anterior submuscular transposition at the elbow, lengthening of the flexor pronator muscle mass in the proximal forearm to accommodate the submuscular position of the ulnar nerve. | Orthopedic | Carpal Tunnel Release - 3 | PREOPERATIVE DIAGNOSES:,1. Left carpal tunnel syndrome (354.0).,2. Left ulnar nerve entrapment at the elbow (354.2).,POSTOPERATIVE DIAGNOSES:,1. Left carpal tunnel syndrome (354.0).,2. Left ulnar nerve entrapment at the elbow (354.2).,OPERATIONS PERFORMED:,1. Left carpal tunnel release (64721).,2. Left ulnar nerv... | orthopedic, carpal tunnel syndrome, ace bandage, kerlix, carpal tunnel release, curvilinear incision, flexor pronator muscle, ping-pong ball sign, synovium, ulnar artery, ulnar nerve, ulnar nerve entrapment, pronator muscle mass, transverse carpal, carpal ligament, tunnel release, flexor pronator, pronator muscle, carp... |
2,292 | Left calcaneal lengthening osteotomy with allograft, partial plantar fasciotomy, posterior subtalar and tibiotalar capsulotomy, and short leg cast placed. | Orthopedic | Calcaneal Lengthening Osteotomy | PREOPERATIVE DIAGNOSES:, Left calcaneal valgus split.,POSTOPERATIVE DIAGNOSES:, Left calcaneal valgus split.,PROCEDURES: ,1. Left calcaneal lengthening osteotomy with allograft.,2. Partial plantar fasciotomy.,3. Posterior subtalar and tibiotalar capsulotomy.,4. Short leg cast placed.,ANESTHESIA: , Surgery perfor... | orthopedic, calcaneal lengthening, osteotomy, allograft, plantar fasciotomy, capsulotomy, calcaneal valgus split, partial plantar fasciotomy, short leg cast, achilles lengthening, calcaneal valgus, tourniquet, plantar, valgus, achilles, calcaneal, |
2,293 | Carpal tunnel release. Nerve conduction study tests diagnostic of carpal tunnel syndrome. The patient failed to improve satisfactorily on conservative care, including anti-inflammatory medications and night splints. | Orthopedic | Carpal Tunnel Release | PROCEDURE PERFORMED: , Carpal tunnel release.,INDICATIONS FOR SURGERY: , Nerve conduction study tests diagnostic of carpal tunnel syndrome. The patient failed to improve satisfactorily on conservative care, including anti-inflammatory medications and night splints.,PROCEDURE: ,The patient was brought to the operating... | orthopedic, carpal tunnel syndrome, carpal ligament, nerve conduction study, carpal tunnel release, bier block, carpal tunnel, tunnel, carpal, |
2,294 | Bunionectomy, SCARF type, with metatarsal osteotomy and internal screw fixation, left and arthroplasty left second toe. Bunion left foot and hammertoe, left second toe. | Orthopedic | Bunionectomy & Metatarsal Osteotomy | PREOPERATIVE DIAGNOSES:,1. Bunion left foot.,2. Hammertoe, left second toe.,POSTOPERATIVE DIAGNOSES:,1. Bunion left foot.,2. Hammertoe, left second toe.,PROCEDURE PERFORMED:,1. Bunionectomy, SCARF type, with metatarsal osteotomy and internal screw fixation, left.,2. Arthroplasty left second toe.,HISTORY: ,This 3... | orthopedic, hammertoe, osteotomy, internal screw fixation, scarf type, extensor digitorum, metatarsal osteotomy, foot, toe, metatarsal, bunionectomy, |
2,295 | Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot. Akin bunionectomy, right toe with internal wire fixation. | Orthopedic | Bunionectomy & Osteotomy | PREOPERATIVE DIAGNOSES:,1. Hallux valgus, right foot.,2. Hallux interphalangeus, right foot.,POSTOPERATIVE DIAGNOSES:,1. Hallux valgus, right foot.,2. Hallux interphalangeus, right foot.,PROCEDURES PERFORMED:,1. Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot.,2. Akin b... | orthopedic, hallux interphalangeus, osteotomy, bunionectomy, akin, wire fixation, screw fixation, painful bunion, metatarsophalangeal joint, pneumatic ankle, metatarsal head, foot, toe, sagittal, metatarsal |
2,296 | Endoscopic release of left transverse carpal ligament. Steroid injection, stenosing tenosynovitis of right middle finger. | Orthopedic | Carpal Ligament Release - 2 | PREOPERATIVE DIAGNOSES:,1. Left carpal tunnel syndrome.,2. Stenosing tenosynovitis of right middle finger (trigger finger).,POSTOPERATIVE DIAGNOSES:,1. Left carpal tunnel syndrome.,2. Stenosing tenosynovitis of right middle finger (trigger finger).,PROCEDURES:,1. Endoscopic release of left transverse carpal ligame... | orthopedic, carpal tunnel syndrome, agee inside job, steroid injection, antebrachial fascia, forearm, ring ray, synovial elevator, tenosynovitis, tourniquet, transverse incision, trigger finger, tenosynovitis of right middle, transverse carpal ligament, transverse carpal, carpal ligament, steri strips, stenosing tenosy... |
2,297 | Bunion, left foot. Bunionectomy with first metatarsal osteotomy base wedge type with internal screw fixation and Akin osteotomy with internal wire fixation of left foot. | Orthopedic | Bunionectomy & Akin Osteotomy | PREOPERATIVE DIAGNOSIS: , Bunion, left foot.,POSTOPERATIVE DIAGNOSIS: ,Bunion, left foot.,PROCEDURE PERFORMED:,1. Bunionectomy with first metatarsal osteotomy base wedge type with internal screw fixation.,2. Akin osteotomy with internal wire fixation of left foot.,HISTORY: , This 19-year-old Caucasian female presents... | orthopedic, bunionectomy, akin osteotomy, internal wire fixation, internal screw fixation, osteotomy, metatarsal, metatarsal osteotomy, extensor digitorum, drill hole, osteotomy site, foot |
2,298 | Bunionectomy, right foot with Biopro hemi implant, right first metatarsophalangeal joint. Arthrodesis, right second, third, and fourth toes with external rod fixation. Hammertoe repair, right fifth toe. Extensor tenotomy and capsulotomy, right fourth metatarsophalangeal joint. Modified Tailor's bunionectomy, right... | Orthopedic | Bunionectomy & Arthrodesis | PREOPERATIVE DIAGNOSES:,1. Hallux abductovalgus, right foot.,2. Hammer toe, right foot, second, third, fourth and fifth toes.,3. Tailor's bunionette, right foot.,4. Degenerative joint disease, right first metatarsophalangeal joint.,5. Rheumatoid arthritis.,6. Contracted fourth right metatarsophalangeal joint.,POS... | null |
2,299 | Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot. Proximal interphalangeal joint arthroplasty, bilateral fifth toes. Distal interphalangeal joint arthroplasty, bilateral third and fourth toes. Flexor tenotomy, bilateral third toes. | Orthopedic | Bunionectomy & Flexor Tenotomy | PREOPERATIVE DIAGNOSES:,1. Hallux abductovalgus, right foot.,2. Hammertoe, bilateral third, fourth, and fifth toes.,POSTOPERATIVE DIAGNOSES:,1. Hallux abductovalgus, right foot.,2. Hammertoe, bilateral third, fourth, and fifth toes.,PROCEDURE PERFORMED:,1. Bunionectomy with distal first metatarsal osteotomy and in... | orthopedic, hallux abductovalgus, hammertoe, bunionectomy, flexor, tenotomy, interphalangeal, arthroplasty, screw fixation, osteotomy, interphalangeal joint arthroplasty, distal interphalangeal joint, interphalangeal joint, flexor tenotomy, proximal interphalangeal, joint arthroplasty, distal interphalangeal, distal, b... |
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