Medical Scenario

medical checkup checkup SCENARIO FOR PARTS 1 & 2 FINAL PROJECT Assignment course session 1. AMBULATORY CARE FACE SHEET Admit Date 7/8/20XX 2022 Discharge Date/Time 7/9/20XX 1010 Sex M Age 47 Disposition Home Admitting diagnosis Possible torn meniscus of the left knee. Discharge Diagnosis Left Knee meniscectomy. Procedures Laparoscopic Surgery to the Left Knee. point of reference Date of Consultation 7/8/20XX This is a 47-year-old male who was in his usual state of health until today entered the Emergency Room with sedate pain to his left knee and equal amount of edema indoors the patellar atomic number 18a.This occurred after the for perambulator fell at an angle on the left knee during a game of football with friends. The patient was evaluated with L-Knee skiagraph and Magnetic Radiograph Imaging (magnetic resonance imaging) for soft-tissue films. The L-Knee X-Ray revealed no fractures to the Femur, Patella, Tibia, or Fibula. The MRI revealed a large tear surrounding th e meniscus of the left knee. The patient was treated with a left knee splint and crutches with a prescription(prenominal) for Mobic 15mg daily and Tramadol/APAP 37. 5 mg every 4-6 hours for pain. The patient was referred to Orthopedics for operative repair.He has no past history of tobacco abuse, previous fractures, or surgeries. 2. past medical History Allergies No known drug allergies. Medications None. Surgeries None Medical History History of Chronic Otitis Externa Family History Noncontributory. Review of Systems No medical abnormalities. Physical Examination Vital Signs BP 130/80, P 92, T 98. 5 General This is a well-developed and well-nourished anxious black male in mild distress. Head and neck are normocephalic and the oropharynx is clear. The left knee shows 5+ edema and patient is unable to bend at knee correlative connection.The patients left leg is not weight bearing and the pain level continues to be a 6 to 7 on the pain scale. The patient is using crutches and wheel chair for mobility. All other musculoskeletal joints are with free range of motion. Neurologic with no focal deficits. Impression inpatient laparoscopic surgery for tot left knee meniscectomy. Local anesthetic total block of the patellar region. 3. OPERATIVE REPORT Date of Procedure 7/8/20XX Procedure Laparoscopic Meniscectomy of Left Knee surgical Medication meperidine 50 mg IV, Robinal 3 mg IV, Xylocaine with 1% Epinephrine Preoperative Diagnosis . Total Left Knee Meniscus Tear. Postoperative Diagnosis Laparoscopic Meniscectomy of Left Knee Clinical Note This is a 47-year-old black male with a total meniscus tear of the left knee caused by a causal game of tag football. The patient felt a pop after falling on the left knee at an angle causing severe pain and edema. The patient was taken to the touch room for x-rays of the left leg and MRI to the left patellar region. He was referred to the othropedics clinic for laparoscopic surgery to the left knee meniscus.Findings After obt aining informed consent, he was premedicated with Demerol, Robinal, Xylocaine with 1% Epinephrine without any complications. The patients left knee was laparoscoped in the meniscus and the anterolateral and anteromedial parapatellar portholes. The synovial membrane in the suprapatellar pouch showed moderate to severe inflammatory changes with villi formation and hyperemia. same changes were noted in the intercondylar groove. The patient tolerated the procedure well, and his post-procedure vital signs are stable. Recommendations 1. puddle liquids for 24 hours. 2. Follow-up in the office in 2 days.