question archive PRIMARY DIAGNOSIS: Fractured left hip

PRIMARY DIAGNOSIS: Fractured left hip

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PRIMARY DIAGNOSIS: Fractured left hip.

CLINICAL INFORMATION: Left hip pain. No known allergies. Orthopedic device is noted transfixing the left femoral neck. I have no old films available for comparison. The left femoral neck region appears anatomically aligned. At the level of an orthopedic screw along the lateral aspect of the femoral neck, approximately at the level of the lesser trochanter, there is a radiolucent band consistent with a fracture of indeterminate age that shows probable nonunion. There is bilateral marginal sclerosis and moderate offset and angulation at this site. Fairly exuberant callus formation is noted laterally along the femoral shaft.

IMPRESSION:1.No evidence for significant displacement at the femoral neck.

2.Probable nonunion of fracture transversely through the shaft of the femur at about the level of the lesser trochanter.

Neil Nofsinger, M.D.

NN:xx

D:08/05/20

XXT:08/05/20XX

RADIOLOGY REPORT (pg.103)

Patient Name: Marietta

Mosley Hospital No.: 11446

X-ray No.: 98-2801

Admitting Physician: John Youngblood, M.D.

Procedure: Left hip x-ray.

Date: 08/05/20XX

PRIMARY DIAGNOSIS: Fractured left hip.

CLINICAL INFORMATION: Left hip pain. No known allergies. Orthopedic device is noted transfixing the left femoral neck. I have no old films available for comparison. The left femoral neck region appears anatomically aligned. At the level of an orthopedic screw along the lateral aspect of the femoral neck, approximately at the level of the lesser trochanter, there is a radiolucent band consistent with a fracture of indeterminate age that shows probable nonunion. There is bilateral marginal sclerosis and moderate offset and angulation at this site. Fairly exuberant callus formation is noted laterally along the femoral shaft.

IMPRESSION:1.No evidence for significant displacement at the femoral neck.

2.Probable nonunion of fracture transversely through the shaft of the femur at about the level of the lesser trochanter.

Neil Nofsinger, M.D.

NN:xxD:08/05/20

XXT:08/05/20XX

DISCHARGE SUMMARY (pg.105)

Patient Name: Joyce

Mabry Hospital No.: 11709

Admitted: 02/18/20XX

Discharged: 02/24/20XX

Consultations: Tom Moore, M.D.,

Hematology Procedures: Splenectomy.

Complications: None.

Admitting Diagnosis: Elective splenectomy for idiopathic thrombocytopenic purpura and systemic lupus erythematosus.

HISTORY: The patient is a 21-year-old white woman who had noted excessive bruising since last June. She was diagnosed as having thrombocytopenic purpura. At the same time, the diagnosis of systemic lupus erythematosus was made. The patient continues with the bruising. The patient had been treated with steroids, prednisone 20 mg; however, the platelet count has remained low, less than 20,000. The patient was admitted for elective splenectomy.

LABORATORY DATA ON ADMISSION: Chest x-ray was negative. Electrocardiogram was normal. Sodium 138, potassium 5.2, chloride 104, CO2 25, glucose 111. Urinalysis negative. Hemoglobin 14.8, hematocrit 43.5, white blood cell counts 15,000, platelet count 17,000, PT 11.5, PTT 27.

HOSPITAL COURSE: The patient was taken to the operating room on February 19 where a splenectomy was performed. The patient’s postoperative course was uncomplicated with the wound healing well. The platelet count was stable for the first 3 postoperative days. The patient was transfused intraoperatively with 10 units of platelets and postoperatively with 10 additional units of platelets. However, on the fourth postoperative day the platelet count had risen to 77,000, which was a significant increase. The patient was discharged for follow-up in my office. She will also be seen by Dr. Moore, who will follow her SLE and ITP.

DISCHARGE DIAGNOSIS: Idiopathic thrombocytopenic purpura and systemic lupus erythematosus.

DISCHARGE MEDICATIONS:

1.Prednisone 20 mg q.d.

2.Percocet 1 to 2 p.o. q. 4 h. p.r.n.

3.Multivitamins, 1 in a.m. q.d.

Carmen Garcia, M.D.

CG:xxD:02/25/20XX

T:02/26/20XX

OPERATIVE REPORT (pg. 106)

Patient Name: Kathy

Sullivan Hospital No.: 11525

Date of Surgery: 06/25/20XX

Admitting Physician: Taylor Withers, M.D.

Surgeons: Sang Lee, M.D., Taylor Withers, M.D.

Preoperative Diagnosis: Urinary incontinence secondary to cystourethrocele.

Postoperative Diagnosis: Urinary incontinence secondary to cystourethrocele.

Operative Procedure: Total abdominal hysterectomy with Marshall-Marchetti correction.

Anesthesia: General endotracheal.

DESCRIPTION: After an abdominal hysterectomy had been performed by Dr. Withers, the peritoneum was closed by him and the procedure was turned over to me. At this time the supravesical space was entered. The anterior portions of the bladder and urethra were dissected free by blunt and sharp dissection. Bleeders were clamped and electro coagulated as they were encountered. A wedge of the overlying periosteum was taken and roughened with a bone rasp. The urethra was then attached to the overlying symphysis by placing two No. 1 catgut sutures on each side of the urethra and one in the bladder neck. The urethra and bladder neck pulled up to the overlying symphysis bone very easily with no tension on the sutures. Bleeding was controlled by pulling the bladder neck up to the bone. Penrose drains were placed on each side of the vesical gutter. Blood loss was negligible. The procedure was then turned back over to Dr. Withers, who proceeded with closure.

Sang Lee, M.D.

SL:xx

D:06/25/20XX

T:06/26/20XX

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