Practicode V (401-500)
MEDICAL RECORD
SEX: MALEAGE: 26DATE OF OPERATION: 1/1/20XXPREOPERATIVE DIAGNOSIS:
DISPLACED LEFT ANKLE BIMALLEOLAR EQUIVALENT FRACTURE.PROCEDURES:
LEFT ANKLE ORIF, LATERAL MALLEOLUS.POSTOPERATIVE DIAGNOSIS: LEFT
ANKLE DISPLACED FRACTURE OF LATERAL MALLEOLUS OF LEFT FIBULA WITH
DISRUPTION OF SYNDEMOSISSURGEON:ANESTHESIA: GENERAL,
ENDOTRACHEAL TUBE.ESTIMATE BLOOD LOSS: 25 CC.TOURNIQUET TIME:
NONE.ANTIBIOTICS: 1 GM ANCEF PREOP AND 1 GM ANCEF
POSTOP.COMPLICATIONS: NONE.INDICATIONS: The patient is a male who was
rollerblading and sustained an injury to the left ankle, which was bimalleolar
equivalent with fracture dislocation. This was closed reduced in the emergency room
CaseID: OPD6928 but was unstable. Options, risks and benefits were discussed with the patient and he
Primary Diagnosis: S82.62XA agreed with the open reduction internal fixation.PROCEDURE: The patient was
Secondary Diagnosis: S93.492A, Y93.51 brought to the operating room and anesthesia was induced via the
CPT: 27829-LT, 27792-LT endotracheal tube. The left lower extremity was prepped and draped in sterile
fashion.A longitudinal incision was made over the lateral malleolus and taken
down through the subcutaneous tissue to the fracture site which was
subperiosteally dissected, irrigated out and curetted. Anatomic reduction was
performed and held with a clamp. A 3.5 drill was then used to create a gliding hole
in the proximal fragment and then a 2.5 drill to the drill distal. This measured and
interfragmentary screw was placed.A 6-hole one-third tubular plate from Smith &
Nephew was then placed along the lateral cortex and the proximal three holes
were filled with cortical screws. The syndesmosis was viewed, and disruption and
we elected to put in two syndesmotic screws which was done by holding the
syndesmosis reduced in a neutral.This was done with 3 cortex technique using 3.5
cortical screws and then another cortical screw was placed distally. The
interfragme
, MEDICAL RECORD
Age: 16 Sex: FemaleDate of Service: 1/1/20XXService Department: Orthopedic Group
GeneralPREOPERATIVE DIAGNOSIS: Left fifth metacarpal base
fracture.POSTOPERATIVE DIAGNOSIS: Left fifth metacarpal base fracture.NAME OF
PROCEDURE:1. Closed reduction pin fixation of the left fifth metacarpal base
fracture.2. Intraoperative use of fluoroscopy.SURGEON: Dr. MDINDICATIONS: The
patient is a female who presents with a displaced left fifth base metacarpal
fracture.DESCRIPTION OF PROCEDURE: The patient was taken to the operating
CaseID: OPD6943
room where she was first given axillary block anesthesia. Next her forearm and hand
Primary Diagnosis: S62.317A
were prepped and draped in the normal sterile circumferential fashion. Next her arm
CPT: 26608
was exsanguinated, tourniquet inflated 250 mmHg. Next, I manipulated the fracture
and was able to get satisfactory reduction. I then placed one 0.62 K-wire across the
fracture site through the joint. I used the image intensifier to assess the reduction,
and placement of this wire which were both deemed to be quite good. At that point I
bent and cut the wire, irrigated the pin site, released tourniquet for a total
tourniquet time of 6 minutes. The patient was then placed in dressing and ulnar
gutter splint. She tolerated the procedure well, and was sent to the discharge
area in stable condition.Electronically signed by 1/1/20XX
MEDICAL RECORD
Age: 60Sex: FEMALEDate of Service: 1/1/20XXService Department: Orthopedic
Group GeneralPREOPERATIVE DIAGNOSIS: (Degenerative) primary osteoarthritis of
right shoulder.POSTOPERATIVE DIAGNOSIS: Same.NAME OF PROCEDURE:
Arthroplasty, glenohumeral joint; hemiarthroplastySURGEON:DESCRIPTION OF
PROCEDURE: The patient was taken to the Operating Room and after
satisfactory general anesthesia, her right shoulder was thoroughly scrubbed,
prepped and draped in the usual sterile manner. The shoulder was incised
longitudinally at the deltopectoral interval, starting just distal and anterior to the
distal clavicle and lateral to the coracoid process. The incision was carefully
carried down through subcutaneous tissue. The deltopectoral interval was
CaseID: OPD6944
identified and the deltoid was retracted laterally and the pectoralis medially. The
Primary Diagnosis: M19.011
Hawkins-Bell retractor was then inserted and the deltoid reflected laterally and the
CPT: 23470-RT
short head of the biceps medially. The pectoral fascia was incised. The scapularis
was incised at it's insertion on the proximal humerus and reflected medially. The
shoulder was then dislocated anteriorly. The Biomet guide was then inserted and
the humeral head resected at 45 degrees of retroversion angle. Then using the
Biomet reamers, the patient's shoulder was reamed at a size 9. The broach was then
inserted. The glenoid was inspected and was quite smooth. There was no glenoid
wear. Therefore, this was left alone. The punch was used to create the keel and the
final prosthesis selected with appropriate matching humeral head. This was
impacted into the humerus. The head was then impacted on the Morse taper of
the stem and shoulder reduced. The patient had excellent range of motion and
stability. The insertion site for the subscapularis had been prepared prior to the
insertion of the prosthesis, by placing dr
, MEDICAL RECORD
SEX: Female AGE: 70DATE OF OPERATION: 1/1/20XXPREOPERATIVE DIAGNOSIS:1.
ADVANCED DEGENERATIVE JOINT - RIGHT KNEE2. VALGUS
DEFORMITYPROCEDURES: RIGHT TOTAL KNEE ARTHROPLASTYPOSTOPERATIVE
DIAGNOSIS: ADVANCED PRIMARY DEGENERATIVE JOINT-RIGHT KNEE; VALGUS
DEFORMITYSURGEON: Dr. MDANESTHESIA:
GENERAL.ANESTHESIOLOGIST:PROCEDURE: After adequate induction with general
anesthesia and the patient in the 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 knee
surgery. An Esmarch tourniquet was applied to the right lower extremity which was
CaseID: OPD6946
elevated for a period of two minutes. The pneumatic tourniquet was inflated to the
Primary Diagnosis: M17.11
appropriate level and the Esmarch was removed. The Alvarado apparatus was
Secondary Diagnosis: M21.061
applied to the right leg with Coban.A linear incision was made along the anterior
CPT: 27447-RT
aspect of the right knee extending from the distal quadriceps, over the mid patella
and terminating at the tibial tubercle. The incision was brought down through
subcutaneous tissue and undermined medially. A medial capsular peripatellar
incision was made extending from the proximal quadriceps raphe and ending at
the tibial tubercle. The patella was mobilized laterally and the infrapatellar fat pad
was excised. The anteromedial and anterolateral capsules of the proximal tibia
were elevated. The knee was flexed and the patella was everted. Advanced
degenerative changes of the interior of the right knee were observed. The
extramedullary rod was applied to the mechanical axis of the tibia and pin fixed
proximally. A proximal tibial cut was made, having determined the height by 10-mm
of the medial tibial plateau. The alignment rod was removed. A drill hole was made
through the distal femur and the intramed
, MEDICAL RECORD
OPERATIVE REPORT
SEX: Male AGE: 34
DATE OF OPERATION: 01/01/20XX
PREOPERATIVE DIAGNOSIS: RIGHT KNEE TORN ANTERIOR CRUCIATE LIGAMENT,
TORN MEDIAL MENISCUS.
PROCEDURES: RIGHT KNEE ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION
WITH ACHILLES TENDON ALLOGRAFT ALL SOFT TISSUE AND PARTIAL MEDIAL
MENISCECTOMY.
POSTOPERATIVE DIAGNOSIS: RIGHT KNEE TORN ANTERIOR CRUCIATE
LIGAMENT, TORN MEDIAL MENISCUS.
SURGEON: M.D.
ANESTHESIA: GENERAL VIA ENDOTRACHEAL TUBE.
ESTIMATE BLOOD LOSS: 10 CC.
TOURNIQUET TIME: 83 MINUTES.
CaseID: OPD6962 ANTIBIOTICS: ANCEF 1 GM PREOP, ANCEF 1 GM POSTOP.
Primary Diagnosis: S83.511A, S83.241A COMPLICATIONS: NONE.
CPT: 29888-RT, 29881-RT INDICATIONS: The patient is a male who sustained an injury to the right knee six
months ago, who was complaining of instability and pain. He was found on physical
exam to have instability with the positive Lachman, positive Pivot shift. On MRI, he
was found to have torn ACL and a probable torn medial meniscus. Options, risks
and benefits were discussed with the patient. He agreed with anterior cruciate
ligament reconstruction with hamstring if suitable and if not allograft.
PROCEDURE: The patient was brought to the operating room and anesthesia
was induced via endotracheal tube. Examination under anesthesia confirmed 2+
Lachman in the right knee and 1+ Pivot shift which were negative Lachman and
negative Pivot shift on the left knee. The right lower extremity was prepped and
draped in sterile fashion. His bony landmarks were marked and incisions were
infiltrated with the 50:50 mixture of 1% lidocaine with epinephrine and 25%
Marcaine. The incision to harvest the hamstrings, tendons was created first which
was centered between the tibial tubercle in the posterior aspect of the tibia
approximately 4 cm below the joint line. It was taken down through subcutaneous
tissues and sartorius fascia which was opened between the two tendons. The
graci
MEDICAL RECORD
SEX: MALEAGE: 26DATE OF OPERATION: 1/1/20XXPREOPERATIVE DIAGNOSIS:
DISPLACED LEFT ANKLE BIMALLEOLAR EQUIVALENT FRACTURE.PROCEDURES:
LEFT ANKLE ORIF, LATERAL MALLEOLUS.POSTOPERATIVE DIAGNOSIS: LEFT
ANKLE DISPLACED FRACTURE OF LATERAL MALLEOLUS OF LEFT FIBULA WITH
DISRUPTION OF SYNDEMOSISSURGEON:ANESTHESIA: GENERAL,
ENDOTRACHEAL TUBE.ESTIMATE BLOOD LOSS: 25 CC.TOURNIQUET TIME:
NONE.ANTIBIOTICS: 1 GM ANCEF PREOP AND 1 GM ANCEF
POSTOP.COMPLICATIONS: NONE.INDICATIONS: The patient is a male who was
rollerblading and sustained an injury to the left ankle, which was bimalleolar
equivalent with fracture dislocation. This was closed reduced in the emergency room
CaseID: OPD6928 but was unstable. Options, risks and benefits were discussed with the patient and he
Primary Diagnosis: S82.62XA agreed with the open reduction internal fixation.PROCEDURE: The patient was
Secondary Diagnosis: S93.492A, Y93.51 brought to the operating room and anesthesia was induced via the
CPT: 27829-LT, 27792-LT endotracheal tube. The left lower extremity was prepped and draped in sterile
fashion.A longitudinal incision was made over the lateral malleolus and taken
down through the subcutaneous tissue to the fracture site which was
subperiosteally dissected, irrigated out and curetted. Anatomic reduction was
performed and held with a clamp. A 3.5 drill was then used to create a gliding hole
in the proximal fragment and then a 2.5 drill to the drill distal. This measured and
interfragmentary screw was placed.A 6-hole one-third tubular plate from Smith &
Nephew was then placed along the lateral cortex and the proximal three holes
were filled with cortical screws. The syndesmosis was viewed, and disruption and
we elected to put in two syndesmotic screws which was done by holding the
syndesmosis reduced in a neutral.This was done with 3 cortex technique using 3.5
cortical screws and then another cortical screw was placed distally. The
interfragme
, MEDICAL RECORD
Age: 16 Sex: FemaleDate of Service: 1/1/20XXService Department: Orthopedic Group
GeneralPREOPERATIVE DIAGNOSIS: Left fifth metacarpal base
fracture.POSTOPERATIVE DIAGNOSIS: Left fifth metacarpal base fracture.NAME OF
PROCEDURE:1. Closed reduction pin fixation of the left fifth metacarpal base
fracture.2. Intraoperative use of fluoroscopy.SURGEON: Dr. MDINDICATIONS: The
patient is a female who presents with a displaced left fifth base metacarpal
fracture.DESCRIPTION OF PROCEDURE: The patient was taken to the operating
CaseID: OPD6943
room where she was first given axillary block anesthesia. Next her forearm and hand
Primary Diagnosis: S62.317A
were prepped and draped in the normal sterile circumferential fashion. Next her arm
CPT: 26608
was exsanguinated, tourniquet inflated 250 mmHg. Next, I manipulated the fracture
and was able to get satisfactory reduction. I then placed one 0.62 K-wire across the
fracture site through the joint. I used the image intensifier to assess the reduction,
and placement of this wire which were both deemed to be quite good. At that point I
bent and cut the wire, irrigated the pin site, released tourniquet for a total
tourniquet time of 6 minutes. The patient was then placed in dressing and ulnar
gutter splint. She tolerated the procedure well, and was sent to the discharge
area in stable condition.Electronically signed by 1/1/20XX
MEDICAL RECORD
Age: 60Sex: FEMALEDate of Service: 1/1/20XXService Department: Orthopedic
Group GeneralPREOPERATIVE DIAGNOSIS: (Degenerative) primary osteoarthritis of
right shoulder.POSTOPERATIVE DIAGNOSIS: Same.NAME OF PROCEDURE:
Arthroplasty, glenohumeral joint; hemiarthroplastySURGEON:DESCRIPTION OF
PROCEDURE: The patient was taken to the Operating Room and after
satisfactory general anesthesia, her right shoulder was thoroughly scrubbed,
prepped and draped in the usual sterile manner. The shoulder was incised
longitudinally at the deltopectoral interval, starting just distal and anterior to the
distal clavicle and lateral to the coracoid process. The incision was carefully
carried down through subcutaneous tissue. The deltopectoral interval was
CaseID: OPD6944
identified and the deltoid was retracted laterally and the pectoralis medially. The
Primary Diagnosis: M19.011
Hawkins-Bell retractor was then inserted and the deltoid reflected laterally and the
CPT: 23470-RT
short head of the biceps medially. The pectoral fascia was incised. The scapularis
was incised at it's insertion on the proximal humerus and reflected medially. The
shoulder was then dislocated anteriorly. The Biomet guide was then inserted and
the humeral head resected at 45 degrees of retroversion angle. Then using the
Biomet reamers, the patient's shoulder was reamed at a size 9. The broach was then
inserted. The glenoid was inspected and was quite smooth. There was no glenoid
wear. Therefore, this was left alone. The punch was used to create the keel and the
final prosthesis selected with appropriate matching humeral head. This was
impacted into the humerus. The head was then impacted on the Morse taper of
the stem and shoulder reduced. The patient had excellent range of motion and
stability. The insertion site for the subscapularis had been prepared prior to the
insertion of the prosthesis, by placing dr
, MEDICAL RECORD
SEX: Female AGE: 70DATE OF OPERATION: 1/1/20XXPREOPERATIVE DIAGNOSIS:1.
ADVANCED DEGENERATIVE JOINT - RIGHT KNEE2. VALGUS
DEFORMITYPROCEDURES: RIGHT TOTAL KNEE ARTHROPLASTYPOSTOPERATIVE
DIAGNOSIS: ADVANCED PRIMARY DEGENERATIVE JOINT-RIGHT KNEE; VALGUS
DEFORMITYSURGEON: Dr. MDANESTHESIA:
GENERAL.ANESTHESIOLOGIST:PROCEDURE: After adequate induction with general
anesthesia and the patient in the 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 knee
surgery. An Esmarch tourniquet was applied to the right lower extremity which was
CaseID: OPD6946
elevated for a period of two minutes. The pneumatic tourniquet was inflated to the
Primary Diagnosis: M17.11
appropriate level and the Esmarch was removed. The Alvarado apparatus was
Secondary Diagnosis: M21.061
applied to the right leg with Coban.A linear incision was made along the anterior
CPT: 27447-RT
aspect of the right knee extending from the distal quadriceps, over the mid patella
and terminating at the tibial tubercle. The incision was brought down through
subcutaneous tissue and undermined medially. A medial capsular peripatellar
incision was made extending from the proximal quadriceps raphe and ending at
the tibial tubercle. The patella was mobilized laterally and the infrapatellar fat pad
was excised. The anteromedial and anterolateral capsules of the proximal tibia
were elevated. The knee was flexed and the patella was everted. Advanced
degenerative changes of the interior of the right knee were observed. The
extramedullary rod was applied to the mechanical axis of the tibia and pin fixed
proximally. A proximal tibial cut was made, having determined the height by 10-mm
of the medial tibial plateau. The alignment rod was removed. A drill hole was made
through the distal femur and the intramed
, MEDICAL RECORD
OPERATIVE REPORT
SEX: Male AGE: 34
DATE OF OPERATION: 01/01/20XX
PREOPERATIVE DIAGNOSIS: RIGHT KNEE TORN ANTERIOR CRUCIATE LIGAMENT,
TORN MEDIAL MENISCUS.
PROCEDURES: RIGHT KNEE ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION
WITH ACHILLES TENDON ALLOGRAFT ALL SOFT TISSUE AND PARTIAL MEDIAL
MENISCECTOMY.
POSTOPERATIVE DIAGNOSIS: RIGHT KNEE TORN ANTERIOR CRUCIATE
LIGAMENT, TORN MEDIAL MENISCUS.
SURGEON: M.D.
ANESTHESIA: GENERAL VIA ENDOTRACHEAL TUBE.
ESTIMATE BLOOD LOSS: 10 CC.
TOURNIQUET TIME: 83 MINUTES.
CaseID: OPD6962 ANTIBIOTICS: ANCEF 1 GM PREOP, ANCEF 1 GM POSTOP.
Primary Diagnosis: S83.511A, S83.241A COMPLICATIONS: NONE.
CPT: 29888-RT, 29881-RT INDICATIONS: The patient is a male who sustained an injury to the right knee six
months ago, who was complaining of instability and pain. He was found on physical
exam to have instability with the positive Lachman, positive Pivot shift. On MRI, he
was found to have torn ACL and a probable torn medial meniscus. Options, risks
and benefits were discussed with the patient. He agreed with anterior cruciate
ligament reconstruction with hamstring if suitable and if not allograft.
PROCEDURE: The patient was brought to the operating room and anesthesia
was induced via endotracheal tube. Examination under anesthesia confirmed 2+
Lachman in the right knee and 1+ Pivot shift which were negative Lachman and
negative Pivot shift on the left knee. The right lower extremity was prepped and
draped in sterile fashion. His bony landmarks were marked and incisions were
infiltrated with the 50:50 mixture of 1% lidocaine with epinephrine and 25%
Marcaine. The incision to harvest the hamstrings, tendons was created first which
was centered between the tibial tubercle in the posterior aspect of the tibia
approximately 4 cm below the joint line. It was taken down through subcutaneous
tissues and sartorius fascia which was opened between the two tendons. The
graci
