Practicode: Practicode II (101-200)
Final Review Exam with Actual
Answers 2025-2026 Updated.
CaseID: OPD6933
Primary Diagnosis: S82.251A
CPT: 27759-RT - Answer 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 to the right lower extremity, which was elevated for a
period of two minutes. The pneumatic tourniquet was inflated to the appropriate level and the
Esmarch 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
CaseID: OPD6934
Primary Diagnosis: M16.11
CPT: 27130-RT - Answer 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 gluteus medius and minimus
freeing the greater trochanter. The capsule was opened anterolaterally in a T-shaped
fashion.The hip was dislocated. The neck was 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
CaseID: OPD6935
Primary Diagnosis: M17.0
CPT: 27447-50 - Answer 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 the subcutaneous tissue to the rectus femoris.
The interval between the rectus and the vastus medialis was incised. This incision was carried
down the medial 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
CaseID: OPD6945
Primary Diagnosis: T84.53XA
Secondary Diagnosis: B95.62
CPT: 29871-RT - Answer 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 OF PROCEDURE: The patient was taken to the operating
room and after satisfactory general anesthesia his right knee was thoroughly scrubbed, prepped
,and draped in the usual manner. The arthroscope was inserted through the medial 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
CaseID: OPD6948
Primary Diagnosis: M80.08XA
Secondary Diagnosis: Z98.890
CPT: 22513-78, 22515-78 - Answer 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 well
for about 3 days and has come back to my office crying in pain. She cannot move. She is just
totally disabled in pain, such severe pain that she has asked to be admitted.I have examined her.
She has no tenderness at her previous 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
CaseID: OPD6953
Primary Diagnosis: S83.241A
Secondary Diagnosis: S83.231A
CPT: 29880-RT - Answer 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 meniscectomy.FINDINGS OF SURGERY: A small flap tear in the mid anterior portion
medial meniscus was encountered, as well as a flap tear in the midportion lateral meniscus and
an inferior cleavage tear of the posterior horn of the lateral 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,
CaseID: OPD6961
Primary Diagnosis: M17.11
Secondary Diagnosis: Z96.698
CPT: 29877-RT - Answer 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 confirm our diagnosis; however, she has had metallic implant in the
past and we could not get the MRI performed. After discussing options with her as her knee
pain persisted, she elected to come to surgery at this time for an arthroscopy of her right 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
CaseID: OPD6968
Primary Diagnosis: I63.231
CPT: 35301-RT, 37605 - Answer MEDICAL RECORD
AGE: 69 SEX: FEMALEDATE OF OPERATION: 1/1/20XX
Final Review Exam with Actual
Answers 2025-2026 Updated.
CaseID: OPD6933
Primary Diagnosis: S82.251A
CPT: 27759-RT - Answer 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 to the right lower extremity, which was elevated for a
period of two minutes. The pneumatic tourniquet was inflated to the appropriate level and the
Esmarch 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
CaseID: OPD6934
Primary Diagnosis: M16.11
CPT: 27130-RT - Answer 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 gluteus medius and minimus
freeing the greater trochanter. The capsule was opened anterolaterally in a T-shaped
fashion.The hip was dislocated. The neck was 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
CaseID: OPD6935
Primary Diagnosis: M17.0
CPT: 27447-50 - Answer 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 the subcutaneous tissue to the rectus femoris.
The interval between the rectus and the vastus medialis was incised. This incision was carried
down the medial 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
CaseID: OPD6945
Primary Diagnosis: T84.53XA
Secondary Diagnosis: B95.62
CPT: 29871-RT - Answer 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 OF PROCEDURE: The patient was taken to the operating
room and after satisfactory general anesthesia his right knee was thoroughly scrubbed, prepped
,and draped in the usual manner. The arthroscope was inserted through the medial 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
CaseID: OPD6948
Primary Diagnosis: M80.08XA
Secondary Diagnosis: Z98.890
CPT: 22513-78, 22515-78 - Answer 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 well
for about 3 days and has come back to my office crying in pain. She cannot move. She is just
totally disabled in pain, such severe pain that she has asked to be admitted.I have examined her.
She has no tenderness at her previous 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
CaseID: OPD6953
Primary Diagnosis: S83.241A
Secondary Diagnosis: S83.231A
CPT: 29880-RT - Answer 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 meniscectomy.FINDINGS OF SURGERY: A small flap tear in the mid anterior portion
medial meniscus was encountered, as well as a flap tear in the midportion lateral meniscus and
an inferior cleavage tear of the posterior horn of the lateral 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,
CaseID: OPD6961
Primary Diagnosis: M17.11
Secondary Diagnosis: Z96.698
CPT: 29877-RT - Answer 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 confirm our diagnosis; however, she has had metallic implant in the
past and we could not get the MRI performed. After discussing options with her as her knee
pain persisted, she elected to come to surgery at this time for an arthroscopy of her right 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
CaseID: OPD6968
Primary Diagnosis: I63.231
CPT: 35301-RT, 37605 - Answer MEDICAL RECORD
AGE: 69 SEX: FEMALEDATE OF OPERATION: 1/1/20XX
