Medical Scenario

medical checkup SCENARIO FOR PARTS 1 & 2 final exam PROJECT appellative Reading 1. ambulatory CARE case SHEET shoot designation 7/8/20XX 2022 drop away Date/ time 7/9/20XX 1010 Sex M Age 47 Disposition national Admitting Diagnosis realistic torn semilunar cartilage of the odd over(p) wing hand articulatio genus joystick. fire Diagnosis leftover genu meniscectomy. agencys Laparoscopic surgical process to the leftover genu. reference point Date of reference point 7/8/20XX This is a 47-year-old potent who was in his accustomed state of health until today entered the requirement Room with concentrated smart to his left human human genu joint and satisfactory amount of dropsy within the patellar argona.This occurred after(prenominal) the affected role fell at an tend on the left knee during a coarse-grained of football with friends. The forbearing was evaluated with L-Knee Radiograph and charismatic Radiograph image (magnetic resonance imaging ) for soft-tissue films. The L-Knee X-Ray revealed no fractures to the Femur, Patella, Tibia, or Fibula. The magnetic resonance imaging revealed a jumbo hitch ring the meniscus of the left knee. The longanimous was tempered with a left knee treat and crutches with a prescription drug for Mobic 15mg daily and Tramadol/APAP 37. 5 mg each 4-6 hours for pain. The persevering was referred to orthopaedics for surgical repair.He has no past taradiddle of tobacco abuse, foregoing fractures, or surgeries. 2. late(prenominal) Medical bill bothergies No know drug allergies. medicinal drugs no(prenominal). Surgeries None Medical score History of inveterate Otitis Externa Family History Noncontributory. analyse of Systems No medical abnormalities. Physical test Vital Signs BP one hundred thirty/80, P 92, T 98. 5 oecumenical This is a well-developed and nourished anxious shameful potent in mild distress. train and neck atomic number 18 normocephalic and the oropharynx is clear. The left knee shows 5+ dropsy and persevering is uneffective to bend at knee joint connection.The patients left leg is not system of weights bearing and the pain level continues to be a 6 to 7 on the pain scale. The patient is using crutches and wheelchair for mobility. All other musculoskeletal joints are with dethaw range of motion. neurological with no focal deficits. Impression convict laparoscopic operation for sum count left knee meniscectomy. Local anesthetic agent total forfend of the patellar region. 3. good REPORT Date of Procedure 7/8/20XX Procedure Laparoscopic Meniscectomy of Left Knee operative Medication Demerol 50 mg IV, Robinal 3 mg IV, Xylocaine with 1% Epinephrine Preoperative Diagnosis . measure Left Knee Meniscus Tear. surgical 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 back of tag football. The patient felt a pop after fall ing on the left knee at an angle causing tremendous pain and edema. The patient was taken to the unavoidableness 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 obtaining conscious consent, he was premedicated with Demerol, Robinal, Xylocaine with 1% Epinephrine without both complications. The patients left knee was laparoscoped in the meniscus and the anterolateral and anteromedial parapatellar portholes. The synovium in the suprapatellar pouch showed throw to severe insurgent changes with villi formation and hyperemia. similar changes were noted in the intercondylar groove. The patient tolerated the social occasion well, and his post-procedure vital signs are stable. Recommendations 1. Clear liquids for 24 hours. 2. Follow-up in the office in 2 days.