5013 Samples in 40 Types as on 07/07/2023

Medical Specialty: Orthopedic

The branch of surgery and medicine concerned with the correction or reconstruction of skeletal and spinal deformities.

Orthopedic
AC Separation Revision & Hardware Removal Removal of the hardware and revision of right AC separation. Loose hardware with superior translation of the clavicle implants. Arthrex bioabsorbable tenodesis screws.
Achilles Lengthening Bilateral open Achilles lengthening with placement of short leg walking cast.
Achilles Ruptured Tendon Right Achilles tendon rupture.
Achilles Tendon Repair Achilles tendon rupture, left lower extremity. Primary repair left Achilles tendon. The patient was stepping off a hilo at work when he felt a sudden pop in the posterior aspect of his left leg. The patient was placed in posterior splint and followed up at ABC orthopedics for further care.
Ankle Pain - Consult The patient was running and twisted her right ankle - right ankle sprain.
Ankle Sprain - H&P History and Physical for right ankle sprain
Anterior Cervical Decompression Herniated nucleus pulposus. Anterior cervical decompression, anterior spine instrumentation, anterior cervical spine fusion, and application of machined allograft.
Anterior Cervical Discectomy Anterior cervical discectomy and removal of herniated disk and osteophytes and decompression of spinal cord and bilateral nerve root decompression. Harvesting of autologous bone from the vertebral bodies. Grafting of allograft bone for creation of arthrodesis.
Anterior Cervical Discectomy - 1 Anterior cervical discectomy, removal of herniated disc and osteophytes, bilateral C4 nerve root decompression, harvesting of bone for autologous vertebral bodies for creation of arthrodesis, grafting of fibular allograft bone for creation of arthrodesis, creation of arthrodesis via an anterior technique with fibular allograft bone and autologous bone from the vertebral bodies, and placement of anterior spinal instrumentation using the operating microscope and microdissection technique.
Anterior Cervical Discectomy - 2 Anterior cervical discectomy at C5-6 and placement of artificial disk replacement. Right C5-C6 herniated nucleus pulposus.
Anterior Cervical Discectomy - 3 Anterior cervical discectomy (two levels) and C5-C6 and C6-C7 allograft fusions. A C5-C7 anterior cervical plate fixation (Sofamor Danek titanium window plate) intraoperative fluoroscopy used and intraoperative microscopy used. Intraoperative SSEP and EMG monitoring used.
Anterior Cervical Discectomy - 4 C5-C6 anterior cervical discectomy, bone bank allograft, and anterior cervical plate. Left cervical radiculopathy.
Anterior Cervical Discectomy & Arthrodesis Anterior cervical discectomy, arthrodesis, partial corpectomy, Machine bone allograft, placement of anterior cervical plate with a Zephyr. 7. Microscopic dissection.
Anterior Cervical Discectomy & Arthrodesis - 1 Arthrodesis - anterior interbody technique, anterior cervical discectomy, anterior instrumentation with a 23-mm Mystique plate and the 13-mm screws, implantation of machine bone implant. Disc herniation with right arm radiculopathy.
Anterior Cervical Discectomy & Arthrodesis - 2 Anterior cervical discectomy C4-C5 arthrodesis with 8 mm lordotic ACF spacer, corticocancellous, and stabilization with Synthes Vector plate and screws. Cervical spondylosis and herniated nucleus pulposus of C4-C5.
Anterior Cervical Discectomy & Decompression Anterior cervical discectomy with decompression C6-C7, arthrodesis with anterior interbody fusion C6-C7, spinal instrumentation using Pioneer 20 mm plate and four 12 x 4.0 mm screws, PEEK implant 7 mm, and Allograft using Vitoss.
Anterior Cervical Discectomy & Decompression - 1 Anterior cervical discectomy with decompression, anterior cervical fusion, anterior cervical instrumentation, and Allograft C5-C6.
Anterior Cervical Discectomy & Fusion Anterior cervical discectomy fusion C3-C4 and C4-C5 using operating microscope and the ABC titanium plates fixation with bone black bone procedure. Cervical spondylotic myelopathy with cord compression and cervical spondylosis.
Anterior Cervical Discectomy & Fusion - 1 Anterior cervical discectomy and fusion, C2-C3, C3-C4. Removal of old instrumentation, C4-C5. Fusion C3-C4 and C2-C3 with instrumentation using ABC plates.
Anterior Cervical Discectomy & Fusion - 2 Herniated nucleus pulposus, C5-C6, with spinal stenosis. Anterior cervical discectomy with fusion C5-C6.
Anterior Cervical Discectomy & Fusion - 3 Radical anterior discectomy with removal of posterior osteophytes, foraminotomies, and decompression of the spinal canal. Anterior cervical fusion. Utilization of allograft for purposes of spinal fusion. Application of anterior cervical locking plate.
Anterior Cervical Discectomy & Fusion - 4 Anterior cervical discectomy with decompression and arthrodesis with anterior interbody fusion. Spinal instrumentation using Pioneer 18-mm plate and four 14 x 4.3 mm screws (all titanium).
Anterior Cervical Discectomy & Fusion - 5 Anterior cervical discectomy at C5-C6 and C6-C7 for neural decompression and anterior interbody fusion at C5-C6 and C6-C7 utilizing Bengal cages x2. Anterior instrumentation by Uniplate construction C5, C6, and C7 with intraoperative x-ray x2.
Anterior Cervical Discectomy & Fusion - 6 Anterior cervical discectomy with decompression of spinal cord. Anterior cervical fusion. Anterior cervical instrumentation. Insertion of intervertebral device. Use of operating microscope.
Anterior Cervical Discectomy & Fusion - 7 C4-C5, C5-C6 anterior cervical discectomy and fusion. The patient is a 62-year-old female who presents with neck pain as well as upper extremity symptoms. Her MRI showed stenosis at portion of C4 to C6.
Anterior Cervical Discectomy & Fusion - 8 C5-C6 anterior cervical discectomy, allograft fusion, and anterior plating.
Anterior Cervical Discectomy & Fusion - 9 Herniated nucleus pulposus C5-C6. Anterior cervical discectomy fusion C5-C6 followed by instrumentation C5-C6 with titanium dynamic plating system, Aesculap. Operating microscope was used for both illumination and magnification.
Anterior Cervical Discectomy & Fusion - Discharge Summary Anterior cervical discectomy and fusions C4-5, C5-6, C6-7 using Bengal cages and Slimlock plate C4 to C7; intraoperative x-ray. Herniated nucleuses pulposus, C5-6 greater than C6-7, left greater than C4-5 right with left radiculopathy and moderate stenosis C5-6.
Anterior Cervical Discectomy & Interbody Fusion Anterior cervical discectomy with decompression, C5-C6, arthrodesis with anterior interbody fusion, C5-C6, spinal instrumentation, C5-C6 using Pioneer 18-mm plate and four 14 x 4.0 mm screws (all titanium), implant using PEEK 7 mm, and Allograft using Vitoss.
Anterior Cervical Discectomy & Interbody Fusion - 1 Anterior cervical discectomy for neural decompression and anterior interbody fusion at C4-C5, C5-C6, and C6-C7 utilizing Bengal cages times three.
Anterior Cervical Discectomy & Interbody Fusion - 2 Anterior cervical discectomy with spinal cord and spinal canal decompression and Anterior interbody fusion at C5-C6 utilizing Bengal cage.
Anterior Cervical Discectomy & Interbody Fusion - 3 Anterior cervical discectomy for neural decompression and anterior interbody fusion C5-C6 utilizing Bengal cage.
Anterior Cervical Discectomy & Osteophytectomy Anterior cervical discectomy and osteophytectomy. Application of prosthetic interbody fusion device. Anterior cervical interbody arthrodesis. Anterior cervical instrumentation
Anterior Cruciate Ligament Reconstruction Arthroscopy of the left knee was performed with the anterior cruciate ligament reconstruction. Removal of loose bodies. Medial femoral chondroplasty and meniscoplasty.
Anterior Lumbar Fusion Anterior lumbar fusion, L4-L5, L5-S1, PEEK vertebral spacer, structural autograft from L5 vertebral body, BMP and anterior plate. Severe low back pain.
Antibiotic-Impregnated Beads Placement Irrigation and debridement of skin, subcutaneous tissue, fascia and bone associated with an open fracture and placement of antibiotic-impregnated beads. Open calcaneus fracture on the right.
Arthrodesis Bilateral Crawford subtalar arthrodesis with open Achilles Z-lengthening and bilateral long-leg cast.
Arthroplasty Hammertoe deformity, left fifth digit and ulceration of the left fifth digit plantolaterally. Arthroplasty of the left fifth digit proximal interphalangeal joint laterally and excision of plantar ulceration of the left fifth digit 3 cm x 1 cm in size.
Arthroplasty - Hammertoe Arthroplasty of the right second digit. Hammertoe deformity of the right second digit.
Arthroscopic Debridement - Shoulder Recurrent anterior dislocating left shoulder. Arthroscopic debridement of the left shoulder with attempted arthroscopic Bankart repair followed by open Bankart arthroplasty of the left shoulder.
Arthroscopic Debridement & Labral Repair - Hip Femoroacetabular impingement. Left hip arthroscopic debridement, femoral neck osteoplasty, and labral repair.
Arthroscopic Meniscoplasty Torn lateral meniscus and chondromalacia of the patella, right knee. Arthroscopic lateral meniscoplasty and patellar shaving of the right knee.
Arthroscopic Rotator Cuff Repair Primary right shoulder arthroscopic rotator cuff repair with subacromial decompression.
Arthroscopic Rotator Cuff Repair - 1 Rotated cuff tear, right shoulder. Glenoid labrum tear. Arthroscopy with arthroscopic glenoid labrum debridement, subacromial decompression, and rotator cuff repair, right shoulder.
Arthroscopic Rotator Cuff Repair - 2 Arthroscopic rotator cuff repair, arthroscopic subacromial decompression, and arthroscopic extensive debridement, superior labrum anterior and posterior tear.
Arthroscopic SLAP lesion Rotator cuff tear, right shoulder. Superior labrum anterior and posterior lesion (peel-back), right shoulder. Arthroscopy with arthroscopic SLAP lesion. Repair of soft tissue subacromial decompression rotator cuff repair, right shoulder.
Arthroscopy - Glenoid Labrum Arthroscopy of the arthroscopic glenoid labrum, rotator cuff debridement shaving glenoid and humeral head, and biceps tenotomy, right shoulder. Massive rotator cuff tear, right shoulder, near complete biceps tendon tear of right shoulder, chondromalacia of glenohumeral joint or right shoulder, and glenoid labrum tear of right shoulder.
Arthroscopy - Shoulder Partial rotator cuff tear, left shoulder. Arthroscopy of the left shoulder with arthroscopic rotator cuff debridement, soft tissue decompression of the subacromial space of the left shoulder.
Arthroscopy & Chondroplasty Diagnostic arthroscopy with partial chondroplasty of patella, lateral retinacular release, and open tibial tubercle transfer with fixation of two 4.5 mm cannulated screws. Grade-IV chondromalacia patella and patellofemoral malalignment syndrome.
Arthroscopy Shoulder/Knee Right shoulder arthroscopy, subacromial decompression, distal clavicle excision, bursectomy, and coracoacromial ligament resection, carpal tunnel release, left knee arthroscopy, and partial medial and lateral meniscectomy.
Arthroscopy, Arthrotomy, Bankart lesion repair Diagnostic arthroscopy exam under anesthesia, left shoulder. Debridement of chondral injury, left shoulder. Debridement, superior glenoid, left shoulder. Arthrotomy. Bankart lesion repair. Capsular shift, left shoulder (Mitek suture anchors; absorbable anchors with nonabsorbable sutures).
Arthroscopy, Meniscoplasty, & Chondroplasty Arthroscopy of the left knee, left arthroscopic medial meniscoplasty of medial femoral condyle, and chondroplasty of the left knee as well. Chondromalacia of medial femoral condyle. Medial meniscal tear, left knee.
Arthrotomy & I&D Hemarthrosis, left knee, status post total knee replacement, rule out infection. Arthrotomy, irrigation and debridement, and polyethylene exchange, left knee. No complications were encountered throughout the procedure.
Arthrotomy & Ostectomy & Capsular Mass Excision Excision of capsular mass and arthrotomy with ostectomy of lateral femoral condyle, right knee. Soft tissue mass and osteophyte lateral femoral condyle, right knee.
Arthrotomy & Subscapularis Tendon Repair Arthrotomy, removal humeral head implant, right shoulder. Repair of torn subscapularis tendon (rotator cuff tendon) acute tear. Debridement glenohumeral joint. Biopsy and culturing the right shoulder.
Aspiration - Knee Joint Erythema of the right knee and leg, possible septic knee. Aspiration through the anterolateral portal of knee joint.
Austin Bunionectomy Austin bunionectomy with internal screw fixation, first metatarsal, left foot.
Austin-Akin Bunionectomy Austin-Akin bunionectomy with internal screw fixation of the first right metatarsophalangeal joint. Weil osteotomy with internal screw fixation, first right metatarsal. Arthroplasty, second right PIP joint.
Austin-Moore Bipolar Hemiarthroplasty Austin-Moore bipolar hemiarthroplasty, left hip utilizing a medium fenestrated femoral stem with a medium 0.8 mm femoral head, a 50 mm bipolar cup. Displace subcapital fracture, left hip.
Back & Leg Pain - Discharge Summary Bilateral l5 spondylolysis with pars defects and spinal instability with radiculopathy. Chronic pain syndrome.
Back Injury IME Back injury with RLE radicular symptoms. The patient is a 52-year-old male who is here for independent medical evaluation.
Back Pain - Discharge Summary Decreased ability to perform daily living activities secondary to exacerbation of chronic back pain.
Bbunionectomy & Metatarsal Osteotomy Tailor's bunionectomy with metatarsal osteotomy of the left fifth metatarsal. Excision of nerve lesion with implantation of the muscle belly of the left second interspace. Excision of nerve lesion in the left third interspace.
Biceps Tendon Repair Ruptured distal biceps tendon, right elbow. Repair of distal biceps tendon, right elbow.
Bilateral Hip Pain A woman presenting to our clinic for the first time for evaluation of hip pain, right greater than left, of greater than 2 years duration. The pain is located laterally as well as anteriorly into the groin.
Bunion & Pes Planovalgus Deformity Evaluation of pain and symptoms related to a recurrent bunion deformity in bilateral feet - recurrent bunion deformity, right forefoot & pes planovalgus deformity, bilateral feet.
Bunionectomy - Austin - Akin Austin/akin bunionectomy, right foot. Bunion, right foot. The patient states she has had a bunion deformity for as long as she can remember that has progressively become worse and more painful.
Bunionectomy & Akin Osteotomy 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.
Bunionectomy & Arthrodesis 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 fifth metatarsal.
Bunionectomy & Flexor Tenotomy 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.
Bunionectomy & Metatarsal Osteotomy Bunionectomy, SCARF type, with metatarsal osteotomy and internal screw fixation, left and arthroplasty left second toe. Bunion left foot and hammertoe, left second toe.
Bunionectomy & Osteotomy Bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot. Akin bunionectomy, right toe with internal wire fixation.
Calcaneal Lengthening Osteotomy Left calcaneal lengthening osteotomy with allograft, partial plantar fasciotomy, posterior subtalar and tibiotalar capsulotomy, and short leg cast placed.
Carpal Ligament Reconstruction 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.
Carpal Ligament Release - 1 Endoscopic release of left transverse carpal ligament.
Carpal Ligament Release - 2 Endoscopic release of left transverse carpal ligament. Steroid injection, stenosing tenosynovitis of right middle finger.
Carpal Tunnel Release 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.
Carpal Tunnel Release - 1 Right carpal tunnel release.
Carpal Tunnel Release - 2 Left endoscopic carpal tunnel release and endotracheal fasciotomy.
Carpal Tunnel Release - 3 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.
Carpal Tunnel Release - 4 Right open carpal tunnel release and cortisone injection, left carpal tunnel.
Carpal Tunnel Release - 5 Bilateral open carpal tunnel release.
Carpal Tunnel Release - 6 Left carpal tunnel release. Left carpal tunnel syndrome. Severe compression of the median nerve on the left at the wrist.
Carpal Tunnel Release - 7 Right carpal tunnel syndrome. Right carpal tunnel release.
Carpal Tunnel Release - 8 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.
Carpal Tunnel Release - 9 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.
Carpal Tunnel Release - Endoscopic 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.
Carpal Tunnel Release - Open 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.
Cartilage Loose Body Removal Left knee arthroscopy with removal of the cartilage loose body and microfracture of the medial femoral condyle with chondroplasty.
Cemented Arthroplasty Left total knee cemented arthroplasty. Severe tricompartmental osteoarthritis, left knee with varus deformity.
Cemented Hemiarthroplasty & Biopsy Left hip cemented hemiarthroplasty and biopsy of the tissue from the fracture site and resected femoral head sent to the pathology for further assessment.
Cervical Spinal Stenosis 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.
Cervical Spondylosis - Neuro Consult 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.
Cervicalgia Postoperative followup note - Cervicalgia, cervical radiculopathy, and difficulty swallowing status post cervical fusion C3 through C7 with lifting of the plate.
Closed ORIF - Ankle 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.
Closed Reduction - 1 Right distal both-bone forearm fracture. Closed reduction under conscious sedation and application of a splint was warranted.
Closed Reduction - 2 Left distal both-bone forearm fracture. Closed reduction with splint application with use of image intensifier.
Closed Reduction Percutaneous Pinning Closed reduction percutaneous pinning, left distal humerus. Closed type-III supracondylar fracture, left distal humerus. Tethered brachial artery, left elbow.
Closing Wedge Osteotomy Closing wedge osteotomy, fifth metatarsal with internal screw fixation, right foot.
Condylectomy Lateral and plantar condylectomy, fifth left metatarsal.
Consult - Back & Leg Pain The patient has been suffering from intractable back and leg pain.
Consult - Knee Pain Patient with complaint of left knee pain. Patient is obese and will be starting Medifast Diet.
CT C-Spine Common CT C-Spine template
CT C-Spine - 1 Axial images through the cervical spine with coronal and sagittal reconstructions.
CT C-Spine - 2 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.
CT Head and C Spine Motor vehicle collision. CT head without contrast and CT cervical spine without contrast. Noncontrast axial CT images of the head were obtained.
CT Head, Facial Bones, Cervical Spine CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast.
CT Head, Facial Bones, Cervical Spine - 1 Motor vehicle collision. CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast.
CT Lumbar Spine 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.
CT Lumbar Spine - 1 This is a middle-aged female with low back pain radiating down the left leg and foot for one and a half years.
CT Lumbar Spine - 2 This is a middle-aged female with two month history of low back pain and leg pain.
CT Neck - 1 CT REPORT - Soft Tissue Neck
CT Neck - 2 CT REPORT - Soft Tissue Neck
CT of Lumbar Spine w/o Contrast CT of Lumbar Spine without Contrast. Patient with history of back pain after a fall.
de Quervain Release - Carpal 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 aponeurosis.
de Quervain Release - Wrist Wrist de Quervain stenosing tenosynovitis. de Quervain release. Fascial lengthening flap of the 1st dorsal compartment.
Debridement - Shoulder 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.
Decompressive Laminectomy 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.
Delayed ORIF 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.
Diagnostic Arthroscopy 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.
Discectomy, Osteophytectomy, & Foraminotomy 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
Discharge Summary - ATV Accident Trauma/ATV accident resulting in left open humerus fracture.
Discharge Summary - Hip Surgery A 47-year-old female with a posttraumatic AV in the right femoral head.
Diskectomy Redo L4-5 diskectomy, left - recurrent herniation L4-5 disk with left radiculopathy.
Diskectomy & Fusion Degenerative disk disease at L4-L5 and L5-S1. Anterior exposure diskectomy and fusion at L4-L5 and L5-S1.
Dorsal Extensor Compartment Release Stenosing tenosynovitis first dorsal extensor compartment/de Quervain tendonitis. Release of first dorsal extensor compartment.
Dorsal Ganglion - Excision Excision dorsal ganglion, right wrist. The extensor retinaculum was then incised and the extensor tendon was dissected and retracted out of the operative field.
Dorsal Ramus & Branch Block 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 anesthetized with 1% Lidocaine.
Dupuytren Disease Excision 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.
Elbow Manipulation Left elbow manipulation and hardware removal of left elbow.
Elbow Pain - Consult Left elbow pain. Fracture of the humerus, spiral. Possible nerve injuries to the radial and median nerve, possibly neurapraxia.
Endoscopic Carpal Tunnel & de Quervain's Release Endoscopic carpal tunnel release and de Quervain's release. Left carpal tunnel syndrome and de Quervain's tenosynovitis.
Endoscopic Carpal Tunnel Rlease Endoscopic carpal tunnel release. Left carpal tunnel syndrome.
Extensor Tendon Repair Left little finger extensor tendon laceration. Repair of left little extensor tendon.
Facetectomy & Foraminotomy 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.
FCR tendinitis Consultation for FCR tendinitis
Finger triggering and locking Consultation for finger triggering and locking.
Five views of the right knee. Sample Radiology report of knee (growth arrest lines).
Flexor Carpi Radialis & Palmaris Longus Repair 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.
Followup Screw Fixation 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.
Foot pain Consultation Consultation for left foot pain.
Foreign Body Removal - Foot 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 wire at work, which somehow got into his shoe. The wire entered his foot.
Foreign Body Removal - Foot - 1 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.
Ganglion Excision Excision of ganglion of the left wrist. A curved incision was made over the presenting ganglion over the dorsal aspect of the wrist.
Hallux Infected Bone Resection Resection of infected bone, left hallux, proximal phalanx, and distal phalanx. Osteomyelitis, left hallux.
Hamstring Release Left distal medial hamstring release.
Hand Pain - Consult 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.
Hardware Removal - Elbow Hardware removal in the left elbow.
Hardware Removal - Metatarsal 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.
Hardware Removal - Ulnar Hardware removal, right ulnar
Hemiarthroplasty - Austin-Moore Bipolar Austin-Moore bipolar hemiarthroplasty, left hip. Subcapital left hip fracture.
Hemiarthroplasty - Discharge Summary Hemiarthroplasty, right hip. Fracture of the right femoral neck, also history of Alzheimer's dementia, hypothyroidism, and status post hemiarthroplasty of the hip.
Hemiarthroplasty - Shoulder 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.
Hemilaminotomy & Foraminotomy Left C5-6 hemilaminotomy and foraminotomy with medial facetectomy for microscopic decompression of nerve root.
Hip Fracture - ER Consult Left hip fracture. The patient is a 53-year-old female with probable pathological fracture of the left proximal femur.
Hip Fracture - Rehab Consult Status post left hip fracture and hemiarthroplasty. Rehab transfer as soon as medically cleared.
Hip Pain Persistent left hip pain. Left hip avascular necrosis. Discussed the possibility of hip arthrodesis versus hip replacement versus hip resurfacing
Hip Surgery - Discharge Summar Decreased ability to perform daily living activity secondary to recent right hip surgery.
Hypergranulation - Consult 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.
I&D - ORIF Wound Postoperative wound infection, complicated. Irrigation and debridement of postoperative wound infection. Removal of foreign body. Placement of vacuum-assisted closure.device.
I&D & Foreign Body Removal 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.
I&D & Open Reduction - Forearm 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.
IME & Record Review - Orthopedic 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.
Ingrown Toenail Removal Painful ingrown toenail, left big toe. Removal of an ingrown part of the left big toenail with excision of the nail matrix.
Intramedullary Nail Fixation Intramedullary nail fixation of the left tibia fracture with a Stryker T2 tibial nail. Left tibial shaft fracture status post gunshot wound.
Intramedullary Rod 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.
Knee & Back Pain Evaluation for chronic pain program
Knee Amputation Left below-the-knee amputation. Dressing change, right foot.
Knee Arthroplasty Bilateral degenerative arthritis of the knees. Right total knee arthroplasty done in conjunction with a left total knee arthroplasty, which will be dictated separately.
Knee Arthroplasty - Bilateral Bilateral knee degenerative arthritis. Bilateral knee arthroplasty. The Zimmer NexGen total knee system was utilized.
Knee Arthroplasty - Discharge Summary Painful right knee status post total knee arthroplasty many years ago. Status post poly exchange, right knee, total knee arthroplasty.
Knee Arthroplasty - Revision Revision right total knee arthroplasty. Right failed total knee arthroplasty.
Knee Arthroscopy Left knee arthroscopy with lateral capsular release.
Knee Arthroscopy - 1 Arthroscopic procedure of the knee.
Knee Arthroscopy & Medial Meniscoplasty Arthroscopy of the left knee with medial meniscoplasty. Internal derangement, left knee. Displaced bucket-handle tear of medial meniscus, left knee.
Knee DJD - Consult Left knee pain and stiffness. Bilateral knee degenerative joint disease (DJD). Significant back pain, status post lumbar stenosis surgery with pain being controlled on methadone 10 mg b.i.d.
Knee Injury Right knee injury suggestive of a recurrent anterior cruciate ligament tear, possible internal derangement. While playing tennis she had a non-contact injury in which she injured the right knee. She had immediate pain and swelling.
Knee Osteoarthrosis - Discharge Summary A 66-year-old female with knee osteoarthrosis who failed conservative management.
Knee Replacement Left medial compartment osteoarthritis of the knee. Left unicompartmental knee replacement.
Knee Surgery - Discharge Summary Decreased ability to perform daily living activities secondary to right knee surgery.
Kyphoplasty KYPHON Balloon Kyphoplasty at T12 and L1evels Insertion of KYPHON HV-R bone cement under low pressure at T12 and L1 levels and bone biopsy.
Kyphoplasty - Consult The patient with an L5 compression fracture.is to come to the hospital for bilateral L5 kyphoplasty. The patient has a history of back and buttock pain for some time.
Kyphoplasty & Vertebroplasty Fracture reduction with insertion of prosthetic device at T8 with kyphoplasty. Vertebroplasties at T7 and T9 with insertion of prosthetic device. Fracture of the T8 vertebra and T9 vertebra.
Kyphosis A 13-year-old new patientfor evaluation of thoracic kyphosis. Family history of kyphosis in a maternal aunt and grandfather. She was noted by her parents to have round back posture.
Laminectomy & Discectomy & Facetectomy Revision laminectomy L5-S1, discectomy L5-S1, right medial facetectomy, preparation of disk space and arthrodesis with interbody graft with BMP. Status post previous lumbar surgery for herniated disk with severe recurrence of axial back pain, failed conservative therapy.
Laminectomy & Facetectomy Complete laminectomy, L4. and facetectomy, L3-L4 level. A dural repair, right sided, on the lateral sheath, subarticular recess at the L4 pedicle level. Posterior spinal instrumentation, L4 to S1, using Synthes Pangea System. Posterior spinal fusion, L4 to S1. Insertion of morselized autograft, L4 to S1.
Laminectomy & Foraminotomy & Cervical Fusion Decompressive left lumbar laminectomy C4-C5 and C5-C6 with neural foraminotomy. Posterior cervical fusion C4-C5. Songer wire. Right iliac bone graft.
Laminectomy & Foraminotomy Followup Followup status post L4-L5 laminectomy and bilateral foraminotomies, and L4-L5 posterior spinal fusion with instrumentation.
Laminectomy & Foraminotomy Revision Microscopic-assisted revision of bilateral decompressive lumbar laminectomies and foraminotomies at the levels of L3-L4, L4-L5, and L5-S1. Posterior spinal fusion at the level of L4-L5 and L5-S1 utilizing local bone graft, allograft and segmental instrumentation. Posterior lumbar interbody arthrodesis utilizing cage instrumentation at L4-L5 with local bone graft and allograft. All procedures were performed under SSEP, EMG, and neurophysiologic monitoring.
Laminotomy, Facetectomy & Foraminotomy Right L4 and L5 transpedicular decompression of distal right L4 and L5 nerve roots. Right L4-L5 and right L5-S1 laminotomies, medial facetectomies, and foraminotomies, decompression of right L5 and S1 nerve roots. Right L4-S1 posterolateral fusion with local bone graft. Left L4 through S1 segmental pedicle screw instrumentation. Preparation harvesting of local bone graft.
Lateral Epicondylitis Release Lateral release with lengthening of the ECRB tendon. Lateral epicondylitis.
Leg Pain - Progress Note History of right leg pain. Leg pain is no longer present.
Ligament Reconstruction & Meniscus Repair Diagnostic operative arthroscopy with repair and reconstruction of anterior cruciate ligament using autologous hamstring tendon, a 40 mm bioabsorbable femoral pin, and a 9 mm bioabsorbable tibial pin. Repair of lateral meniscus using two fast fixed meniscal repair sutures. Partial medial meniscectomy. Partial chondroplasty of patella. Lateral retinacular release. Open medial plication as well of the right knee.
Ligament Reconstruction & Tendon Interposition Arthroplasty Ligament reconstruction and tendon interposition arthroplasty of right wrist.
Long-Arm Cast Closed reduction and placement of long-arm cast.
Low Back Pain - Consult New patient consultation - Low back pain, degenerative disc disease, spinal stenosis, diabetes, and history of prostate cancer status post radiation.
Low Back Pain from Exercise Patient having low back pain after doing exercise
Lower back pain Lumbar muscle strain and chronic back pain. Patient has a history of chronic back pain, dating back to an accident that he states he suffered two years ago.
Lower Extremity Pain Evaluation for right L4 selective nerve root block.
Lumbar Discectomy - Microscopic Microscopic lumbar discectomy, left L5-S1. Extruded herniated disc, left L5-S1. Left S1 radiculopathy (acute). Morbid obesity.
Lumbar Discogram Lumbar discogram L2-3, L3-4, L4-5, and L5-S1. Low back pain.
Lumbar Laminectomy Lumbar laminectomy for decompression with foraminotomies L3-L4, L4-L5, L5-S1 microtechniques and repair of CSF fistula, microtechniques L5-S1, application of DuraSeal. Lumbar stenosis and cerebrospinal fluid fistula.
Lumbar Laminectomy & Discectomy Injection for myelogram and microscopic-assisted lumbar laminectomy with discectomy at L5-S1 on the left. Herniated nucleus pulposus, L5-S1 on the left with severe weakness and intractable pain.
Lumbar Laminotomy & Discectomy Microscopic assisted lumbar laminotomy with discectomy at L5-S1 on the left. Herniated nucleus pulposus of L5-S1 on the left.
Lumbar Puncture - 2 Lumbar puncture. A 20-gauge spinal needle was then inserted into the L3-L4 space. Attempt was successful on the first try and several mLs of clear, colorless CSF were obtained.
Lumbar Radiculopathy - Consult Low back pain, lumbar radiculopathy, degenerative disc disease, lumbar spinal stenosis, history of anemia, high cholesterol, and hypothyroidism.
Lumbar Re-exploration Recurrent degenerative spondylolisthesis and stenosis at L4-5 and L5-S1 with L3 compression fracture adjacent to an instrumented fusion from T11 through L2 with hardware malfunction distal at the L2 end of the hardware fixation.
Lumbar Spine HNP - Consult Low back pain and right lower extremity pain - Lumbar spine herniated nucleus pulposus.
McBride Bunionectomy & Wedge Osteotomy Right hallux abductovalgus deformity. Right McBride bunionectomy. Right basilar wedge osteotomy with OrthoPro screw fixation.
Medial Branch Rhizotomy Medial branch rhizotomy, lumbosacral. Fluoroscopy was used to identify the boney landmarks of the spine and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.
Meniscoplasty & Chondroplasty Arthroscopy, medial meniscoplasty, lateral meniscoplasty, medial femoral chondroplasty, and medical femoral microfracture, right knee. Patellar chondroplasty. Lateral femoral chondroplasty. Meniscal tear, osteochondral lesion, degenerative joint disease, and chondromalacia,
MRI Ankle - 1 Patient with right ankle pain.
MRI Ankle - 2 MRI right ankle.
MRI Brain & T-spine - Demyelinating disease. MRI Brain & T-spine - Demyelinating disease.
MRI Brain and C-T Spine MRI Brain & MRI C-T spine: Multiple hemangioblastoma in Von Hippel Lindau Disease.
MRI C3 - Cord Compression. Left third digit numbness and wrist pain.
MRI Cervical Spine - 1 MRI cervical spine.
MRI Cervical Spine - 2 MRI Cervical Spine without contrast.
MRI Cervical Spine - Chiropractic Specific MRI report Cervical Spine (Chiropractic Specific)
MRI C-spine MRI C-spine: C4-5 Transverse Myelitis.
MRI C-Spine - C5-6 Disk Herniation MRI C-spine to evaluate right shoulder pain - C5-6 disk herniation.
MRI Elbow - 1 MRI Elbow - A middle-aged female complaining of elbow pain.
MRI Elbow - 2 MRI of elbow - A middle-aged female with moderate pain, severe swelling and a growth on the arm.
MRI Foot - 1 Pain and swelling in the right foot, peroneal tendon tear.
MRI Foot - 2 Pain and swelling in the right foot.
MRI Foot - 3 A 49-year-old female with ankle pain times one month, without a specific injury.
MRI Knee - 1 MRI left knee without contrast.
MRI Knee - 2 A 53-year-old female with left knee pain being evaluated for ACL tear.
MRI Knee - 3 MRI left knee.
MRI Knee - 4 MRI left knee without contrast.
MRI Knee - 5 MRI right knee without gadolinium
MRI L-S Spine - Cauda Equina Syndrome MRI L-S-Spine for Cauda Equina Syndrome secondary to L3-4 disc herniation - Low Back Pain (LBP) with associated BLE weakness.
MRI L-Spine - Subarachnoid Seeding MRI L-spine - History of progressive lower extremity weakness, right frontal glioblastoma with lumbar subarachnoid seeding.
MRI of Lumbar Spine w/o Contrast MRI of lumbar spine without contrast to evaluate chronic back pain.
MRI Shoulder - 1 Left shoulder pain. Evaluate for rotator cuff tear.
MRI Shoulder - 2 A 51-year-old female with left shoulder pain and restricted external rotation and abduction x 6 months.
MRI Shoulder - 3 A 32-year-old male with shoulder pain.
MRI Shoulder - 4 A 69-year-old male with pain in the shoulder. Evaluate for rotator cuff tear.
MRI Shoulder - 5 MRI left shoulder.
MRI Spine MRI of the Cervical, Thoracic, and Lumbar Spine
MRI Spine - Epidural Lipoma MRI Spine - T12-L5 epidural lipoma and thoracic spinal cord infarction vs. transverse myelitis.
MRI T-L Spine - Schistosomiasis MRI T-L spine - L2 conus medullaris lesion and syndrome secondary to Schistosomiasis.
MRI T-Spine MRI T-spine and CXR - Aortic Dissection.
MRI T-Spine - 1 The thoracic spine was examined in the AP, lateral and swimmer's projections.
MRI T-Spine - Spinal Mets MRI T-spine: Metastatic Adenocarcinoma of the T3-T4 vertebrae and invading the spinal canal.
MRI Wrist - 1 Patient with wrist pain and swelling, status post injury.
Mumford Procedure & Acromioplasty Arthroscopy with arthroscopic rotator cuff debridement, anterior acromioplasty, and Mumford procedure left shoulder. Partial rotator cuff tear with impingement syndrome. Degenerative osteoarthritis of acromioclavicular joint, left shoulder, rule out slap lesion.
Neck & Back Pain Initial evaulation - neck and back pain.
Neck & Lower Back Pain - Consult Patient status post vehicular trauma. Low Back syndrome and Cervicalgia.
Neck Pain - Discharge Summary Neck pain with right upper extremity radiculopathy and cervical spondylosis with herniated nucleus pulposus C4-C5, C5-C6, and C6-C7 with stenosis.
Nerve & Tendon Repair - Finger Repair of nerve and tendon, right ring finger and exploration of digital laceration. Laceration to right ring finger with partial laceration to the ulnar slip of the FDS which is the flexor digitorum superficialis and 25% laceration to the flexor digitorum profundus of the right ring finger and laceration 100% of the ulnar digital nerve to the right ring finger.
Neuroplasty Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection.
Normal L-Spine MRI MRI L-Spine - Bilateral lower extremity numbness
Olecranon Bursa - Excision Incision and drainage and excision of the olecranon bursa, left elbow. Acute infected olecranon bursitis, left elbow.
Open Plantar Fasciotomy Chronic plantar fasciitis, right foot. Open plantar fasciotomy, right foot.
ORIF - 1 Open reduction and internal fixation of right distal radius fracture - intraarticular four piece fracture and right carpal tunnel release.
ORIF - 2 Open reduction and internal fixation, high grade Frykman VIII distal radius fracture.
ORIF - 3 Open reduction internal fixation of the left supracondylar, intercondylar distal femur fracture.
ORIF - Discharge Summary Open reduction and internal fixation (ORIF) of right Schatzker III tibial plateau fracture with partial medial meniscectomy.
ORIF - Fifth Metatarsal Fractured right fifth metatarsal. Open reduction and internal screw fixation right fifth metatarsal. Application of short leg splint.
ORIF - Followup Followup visit status post removal of external fixator and status post open reduction internal fixation of right tibial plateau fracture.
ORIF - Left Tibia Open reduction and internal fixation of left tibia.
ORIF - Malleolus Open reduction and internal fixation of left lateral malleolus. Left lateral malleolus fracture.
ORIF - Talus Hawkins IV talus fracture. Open reduction internal fixation of the talus, medial malleolus osteotomy, and repair of deltoid ligament.
ORIF & Cervical Fusion Open reduction and internal fixation (ORIF) of comminuted C2 fracture. Posterior spinal instrumentation C1-C3, using Synthes system. Posterior cervical fusion C1-C3. Insertion of morselized allograft at C1to C3.
ORIF & Closed Reduction Open reduction and internal fixation of the left medial epicondyle fracture with placement in a long-arm posterior well-molded splint and closed reduction casting of the right forearm.
ORIF Mandibular Fracture & Dental Implant Removal Open reduction and internal fixation of left atrophic mandibular fracture, removal of failed dental implant from the left mandible. The patient fell following an episode of syncope and sustained a blunt trauma to his ribs resulting in multiple fractures and presumably also struck his mandible resulting in fracture.
ORIF of Left Distal Radius Open reduction and internal fixation of left distal radius.
ORIF Wrist - Acumed Locking Plate Open reduction and internal fixation (ORIF) of the right wrist using an Acumed locking plate. Closed displaced angulated fracture of the right distal radius.
ORIF, Closed Reduction, Screw Fixation, Etc. Open reduction internal fixation (ORIF) with irrigation and debridement of open fracture. Closed reduction and screw fixation of right femoral neck fracture. Retrograde femoral nail using a striker T2 retrograde nail. Irrigation and debridement of knee and elbow abrasions.
Ortho - Letter - 1 A 19-year-old right-handed male injured in a motor vehicle accident.
Ortho - Letter - 2 Patient suffers from neck and lower back pain radiating into both arms and both legs with numbness, paraesthesia, and tingling in both arms.
Ortho Office Visit The patient continues to suffer from ongoing neck and lower back pain with no recent radicular complaints.
Orthopedic Consult Medical management, status post left total knee arthroplasty.
Orthopedic Consult - 1 Low back pain, lumbar degenerative disc disease, lumbar spondylosis, facet and sacroiliac joint syndrome, lumbar spinal stenosis primarily bilateral recess, intermittent lower extremity radiculopathy, DJD of both knees, bilateral pes anserinus bursitis, and chronic pain syndrome.
Orthopedic Consult - 2 Degenerative disk disease of the right hip, low back pain with lumbar scoliosis post laminectomy syndrome, lumbar spinal stenosis, facet and sacroiliac joint syndrome, and post left hip arthroplasty.
Orthopedic Consult - 3 Back pain and right leg pain. Small cell lung cancer with metastasis at the lower lumbar spine, pelvis, and both femurs
Orthopedic Consult - 4 Patient with chronic pain plus lumbar disk replacement with radiculitis and myofascial complaints.
Orthopedic Consult - 5 Patient with back and hip pain.
OssaTron Extracorporeal Shockwave Therapy OssaTron extracorporeal shockwave therapy to right lateral epicondyle. Right lateral epicondylitis.
Osteoarthritis - Progress Note Orthopedic progress note for follow up of osteoarthritis, knees.
Osteosynthesis Acetabular fracture on the left posterior column/transverse posterior wall variety with an accompanying displaced fracture of the intertrochanteric variety to the left hip. Osteosynthesis of acetabular fracture on the left, complex variety and total hip replacement.
Osteotomy & Bunionectomy Distal metaphyseal osteotomy and bunionectomy with internal screw fixation, right foot. Reposition osteotomy with internal screw fixation to correct angulation deformity of proximal phalanx, right foot.
Osteotomy & Bunionectomy - 1 Plantar flex third metatarsal and talus bunion, right foot. Third metatarsal osteotomy, talus bunionectomy, and application of short-leg cast, right foot. Patient has tried conservative methods such as wide shoes and serial debridement and accommodative padding, all of which provided inadequate relief. At this time she desires to attempt a surgical correction.
Pain Management Consult - 1 Pain management for post-laminectomy low back syndrome and radiculopathy.
Pain Management Consult - 2 Entrapment of the Superior Gluteal Nerve in the aponeurosis of the Gluteus Medius-Left.
Pain Management Progress Note Pain management sample progress note.
Patellar Tendon & Retinaculum Repair Patellar tendon and medial and lateral retinaculum repair, right knee. Patellar tendon retinaculum ruptures, right knee.
Pathology - Sesamoid Bone Specimen labeled "sesamoid bone left foot".
Pectoralis Tendon Repair Open repair of right pectoralis major tendon. Right pectoralis major tendon rupture. On MRI evaluation, a complete rupture of a portion of the pectoralis major tendon was noted.
Pediatric Rheumatology Consult A 7-year-old white male started to complain of pain in his fingers, elbows, and neck. This patient may have had reactive arthritis.
Phalanx Amputation Amputation distal phalanx and partial proximal phalanx, right hallux. Osteomyelitis, right hallux.
Physical Therapy - Ankle Sprain Ankle sprain, left ankle. The patient tripped over her dog toy and fell with her left foot inverted. The patient states that she received a series of x-rays and MRIs that were unremarkable. After approximately 1 month, the patient continued to have significant debilitating pain in her left ankle. She then received a walking boot and has been in the boot for the past month.
Physical Therapy - Back Pain Patient was referred to Physical Therapy, secondary to low back pain and degenerative disk disease. The patient states she has had a cauterization of some sort to the nerves in her low back to help alleviate with painful symptoms. The patient would benefit from skilled physical therapy intervention.
Physical Therapy - Low Back Pain The patient is a 26-year-old female, referred to Physical Therapy for low back pain. The patient has a history of traumatic injury to low back.
Physical Therapy - Osteoarthritis The patient is a 58-year-old female, referred to therapy due to left knee osteoarthritis. The patient states that approximately 2 years ago, she fell to the ground and thereafter had blood clots in the knee area. The patient was transferred from the hospital to a nursing home and lived there for 1 year. The patient states that her primary concern is her left knee pain and they desire to walk short distances again in her home.
Physical Therapy - Synovitis Synovitis - anterior cruciate ligament tear of the left knee. The patient is a 52-year-old male, who was referred to Physical Therapy, secondary to left knee pain. The patient fell in a grocery store. He reports slipping on a grape that was on the floor.
Pilon Fracture External Fixation External fixation of left pilon fracture and closed reduction of left great toe, T1 fracture. Due to the comminuted nature of her tibia fracture as well as soft tissue swelling, the patient is in need of a staged surgery with the 1st stage external fixation followed by open treatment and definitive plate and screw fixation.
Pinning - Hip Revision and in situ pinning of the right hip.
Pinning - Ulna Closed reduction and pinning of the right ulna with placement of a long-arm cast.
PMT Halo Crown & Vest Application of PMT large halo crown and vest. Cervical spondylosis, status post complex anterior cervical discectomy, corpectomy, decompression and fusion.
Radiofrequency Ablation Bilateral L5, S1, S2, and S3 radiofrequency ablation for sacroiliac joint pain. Fluoroscopy was used to identify the bony landmarks of the sacrum and the sacroiliac joints and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.
Radiologic Exam - Spine Cervical, lumbosacral, thoracic spine flexion and extension to evaluate back and neck pain.
Records Review - Orthopedic Patient did undergo surgical intervention as related to the right knee and it was noted that the reconstruction had failed. A screw had come loose.
Release of A1 Pulley The patient was found to have limitations to extension at the IP joint to the right thumb and he had full extension after release of A1 pulley.
Release of A1 Pulley - 1 Release of A1 pulley, right thumb. Stenosing tendinosis, right thumb (trigger finger). There was noted to be thickening of the A1 pulley. There was a fibrous nodule noted within the flexor tendon of the thumb, which caused triggering sensation to the thumb.
Rheumatology Progress Note Epicondylitis. history of lupus. Injected with 40-mg of Kenalog mixed with 1 cc of lidocaine.
RICE Therapy A sample note on RICE Therapy
Right Shoulder Hemiarthroplasty Right shoulder hemiarthroplasty. Right shoulder rotator cuff tear. Glenohumeral rotator cuff arthroscopy. Degenerative joint disease.
Rotator Cuff Repair Arthroscopic subacromial decompression and repair of rotator cuff through mini-arthrotomy.
Rotator cuff syndrome - H&P Shoulder pain, right shoulder diffusely - Rotator cuff syndrome, right.
Rotator Cuff Tear Followup left-sided rotator cuff tear and cervical spinal stenosis. Physical examination and radiographic findings are compatible with left shoulder pain and left upper extremity pain, which is due to a combination of left-sided rotator cuff tear and moderate cervical spinal stenosis.
Scarf Bunionectomy Scarf bunionectomy procedure of the first metatarsal of the left foot. Hallux abductovalgus deformity with bunion of the left foot.
Shoulder Contusion Left shoulder injury. A 41-year-old male presenting for initial evaluation of his left shoulder.
Shoulder Hemi-resurfacing Right shoulder hemi-resurfacing using a size 5 Biomet Copeland humeral head component, noncemented. Severe degenerative joint disease of the right shoulder.
Shoulder Pain Consult Consultation for right shoulder pain.
Slipped Capital Femoral Epiphysis (SCFE) Frontal and lateral views of the hip and pelvis.
Spinal Fusion & Instrumentation Posterior spinal fusion and spinal instrumentation. Posterior osteotomy; posterior elements to include laminotomy-foraminotomy and decompression of the nerve roots.
Spinal Manipulation Spinal Manipulation under Anesthesia - Sacro-iliitis, lumbo-sacral segmental dysfunction, thoraco-lumbar segmental dysfunction, associated with myalgia/fibromyositis.
Spine Fusion Anterior spine fusion from T11-L3. Posterior spine fusion from T3-L5. Posterior spine segmental instrumentation from T3-L5, placement of morcellized autograft and allograft.
Styloidectomy Excision of volar radial wrist mass (inflammatory synovitis) and radial styloidectomy, right wrist. Right wrist pain with an x-ray showing a scapholunate arthritic collapse pattern arthritis with osteophytic spurring of the radial styloid and a volar radial wrist mass suspected of being a volar radial ganglion.
Subcutaneous Transposition of Ulnar Nerve Subcutaneous transposition of the right ulnar nerve. Right carpal tunnel syndrome and right cubital tunnel syndrome.
Subperiosteal Abscess Debridement Repeat irrigation and debridement of Right distal femoral subperiosteal abscess.
Superior Labrum Lesions Repair Superior labrum anterior and posterior lesion repair.
Suprapatellar Knee Pain A football athlete presenting for evaluation of left suprapatellar knee pain that began after he sustained a direct blow onto the knee
Symes Amputation - Hallux Excision of mass, left second toe and distal Symes amputation, left hallux with excisional biopsy. Mass, left second toe. Tumor. Left hallux bone invasion of the distal phalanx.
Synovectomy - Partial Arthroscopic irrigation and debridement of same with partial synovectomy. Septic left total knee arthroplasty.
Tailor Bunionectomy with Screw Fixation Tailor bunionectomy, right foot, Weil-type with screw fixation. Hallux abductovalgus deformity and tailor bunion deformity, right foot.
Tarsectomy Painful enlarged navicula, right foot. Osteochondroma of right fifth metatarsal. Partial tarsectomy navicula and partial metatarsectomy, right foot.
Tenosynovectomy & Cortisone Injection Left carpal tunnel release with flexor tenosynovectomy; cortisone injection of trigger fingers, left third and fourth fingers; injection of Dupuytren's nodule, left palm.
Thoracic Discectomy Thoracic right-sided discectomy at T8-T9. The patient is a 53-year-old female with a history of right thoracic rib pain related to a herniated nucleus pulposus at T8-T9.
Three Views - Ankle Pain. Three views of the right ankle. Three views of the right ankle are obtained.
Three Views - Foot Right foot trauma. Three views of the right foot. Three views of the right foot were obtained.
Tibial in situ bypass Right proximal superficial femoral to mid-posterior tibial in situ bypass and right transmetatarsal amputation, fifth toe
Tissue Expander Insertion History of compartment syndrome, right lower extremity, status post 4 compartments fasciotomy, to do incision for compartment fasciotomy. Wound debridement x2, including skin, subcutaneous, and muscle. Insertion of tissue expander to the medial and lateral wound.
TLIF Transforaminal lumbar interbody fusion, placement of intervertebral prosthetic device.
Total Hip Arthroplasty Total hip arthroplasty on the left. Left hip degenerative arthritis. Severe degenerative changes within the femoral head as well as the acetabulum, anterior as well as posterior osteophytes.
Total Hip Arthroplasty - Revision Infected right hip bipolar arthroplasty, status post excision and placement of antibiotic spacer. Removal of antibiotic spacer and revision total hip arthroplasty.
Total Hip Replacement Right hip osteoarthritis. Total hip replacement on the right side.
Total Hip Replacement - 1 Total hip replacement. An incision was made, centered over the greater trochanter. Dissection was sharply carried down through the subcutaneous tissues.
Total Knee Arthoplasty - Right - 1 Right total knee arthroplasty using a Biomet cemented components, 62.5-mm right cruciate-retaining femoral component, 71-mm Maxim tibial component, and 12-mm polyethylene insert with 31-mm patella. All components were cemented with Cobalt G.
Total Knee Arthroplasty Right knee total arthroplasty. Degenerative osteoarthritis, right knee.
Total Knee Arthroplasty - Right Right total knee arthroplasty - Osteoarthritis, right knee.
Total Knee Replacement Total left knee replacement. Degenerative arthritis of the left knee. Degenerative ware of three compartments of the trochlea, the medial, as well as the lateral femoral condyles as well was the plateau.
Total Knee Replacement - 1 Total knee replacement. A midline incision was made, centered over the patella. Dissection was sharply carried down through the subcutaneous tissues. A median parapatellar arthrotomy was performed.
Total Knee Replacement - NexGen NexGen left total knee replacement. Degenerative arthritis of left knee. The patient is a 72-year-old female with a history of bilateral knee pain for years progressively worse and decreasing quality of life and ADLs.
Transpedicular Decompression Foraminal disc herniation of left L3-L4. Enlarged dorsal root ganglia of the left L3 nerve root. Transpedicular decompression of the left L3-L4 with discectomy.
Trigger Finger Release Trigger finger release. A longitudinal incision was made over the digit's A1 pulley. Dissection was carried down to the flexor sheath with care taken to identify and protect the neurovascular bundles. The sheath was opened under direct vision with a scalpel, and then a scissor was used to release it under direct vision from the proximal extent of the A1 pulley to just proximal to the proximal digital crease.
Trigger Thumb Release Trigger thumb release. A transverse incision was made over the MPJ crease of the thumb. Dissection was carried down to the flexor sheath with care taken to identify and protect the neurovascular bundles.
Trigger Thumb Release - 1 Trigger thumb release. Right trigger thumb. The A-1 pulley was divided along its radial border, completely freeing the stenosing tenosynovitis (trigger release).
Ulnar Nerve Decompression Decompression of the ulnar nerve, left elbow. Left cubital tunnel syndrome and ulnar nerve entrapment.
Ulnar Nerve Transposition Subcutaneous ulnar nerve transposition. A curvilinear incision was made over the medial elbow, starting proximally at the medial intermuscular septum, curving posterior to the medial epicondyle, then curving anteriorly along the path of the ulnar nerve. Dissection was carried down to the ulnar nerve.
Ulnar Nerve Transposition & Olecranon Bursa Excision Right ulnar nerve transposition, right carpal tunnel release, and right excision of olecranon bursa. Right cubital tunnel syndrom, carpal tunnel syndrome, and olecranon bursitis.
Vertebroplasty Unilateral transpedicular T11 vertebroplasty.
Wrist Ganglion Excision Excision of dorsal wrist ganglion. Made a transverse incision directly over the ganglion. Dissection was carried down through the extensor retinaculum, identifying the 3rd and the 4th compartments and retracting them.
Wrist Pain Consultation for wrist pain.
Wrist TFCC irritation The patient has been having problems with the wrist. Right wrist TFCC irritation, possible TFCC tear.
Youngswick Bunionectomy Austin & Youngswick bunionectomy with Biopro implant. Screw fixation, left foot.
Youngswick Osteotomy Youngswick osteotomy with internal screw fixation of the first right metatarsophalangeal joint of the right foot.