Utopia University Sports Medicine Center

Transcription

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4 EXHIBIT 5A2 Utopia University Sports Medicine Center 9727 North Morava Blvd., Utopia City, Utopia Phone: (342) Thomas, Sloane, DOB: 01/02/1997 Encounter Note 02/06/2013 Davis, Arya, M.D. This note has been signed by Davis, Arya on 02/06/ :07:46 PM Chief Complaint Sloane Thomas is a 16 year old male. He presents with pain in his right ankle, reportedly as the result of an injury during a high school basketball game. He is here for initial evaluation. History of Present Illness Lateral Malleolus Fracture: Sloane presents for an initial evaluation of ankle pain, which began after an injury during a high school basketball game on 2/5/13. Ankle pain is acute in nature. By report, swelling has increased over the last 20 hours; pain does not improve with NSAIDs and is a 10 on a 10-point scale. Review of Systems MUSCULOSKELETAL: Positive for leg pain and ankle pain. NEUROLOGIC: Positive for numbness in extremities. Physical Exam Musculoskeletal Ankle: Reduced range of motion. Severe swelling. Severe muscle tenderness in the ankle. Reduced ankle flexion strength. Neurologic Consciousness, orientation, cooperation: Alert, fully oriented. Cooperative with exam. X-ray of Right Ankle X-rays of right ankle show right lateral malleolus fracture. Assessment 1. Right Lateral Malleolus Fracture due to sports injury Plan Lateral Malleolus Fracture: Treatment of a stable lateral malleolus fracture should consist of efforts to reduce swelling followed by a gradual progression in weight-bearing. Ice application is helpful at reducing pain and minimizing swelling. Elevation is important to keep swelling limited. Be sure your ankle is above your heart. Nonsteroidal anti-inflammatory medications ( NSAIDs ), including ibuprofen and naproxen, are helpful at controlling both swelling and pain. Rest/Immobilization: While stable ankle fracture can support your weight, it helps to limit weightbearing to help control pain and swelling. Use of crutches for 2 weeks is suggested. Cast installation for immobilization at today s visit. Weekly follow up visits with x-rays monitored by radiology staff to ensure proper healing. Reevaluation in 8 weeks to monitor progress and determine whether cast removal and transition to physical therapy is appropriate. A 1-week course of Vicodin HP is being prescribed for pain management, at which time patient should transition to NSAIDs for relief of ongoing pain. Patient was advised to read Vicodin HP Medication guide and call with any questions.

5 EXHIBIT 5A2 Utopia University Sports Medicine Center 9727 North Morava Blvd., Utopia City, Utopia Phone: (342) Thomas, Sloane, DOB: 01/02/1997 Encounter Note 04/05/2013 Davis, Arya, M.D. This note has been signed by Davis, Arya on 04/05/ :21:24 PM Chief Complaint Sloane Thomas is a 16 year old male, returning for his 8-week follow up evaluation of injury to his right ankle on 2/6/13. History of Present Illness Lateral Malleolus Fracture: Sloane presents for a follow up visit. Ankle pain has been present for 8 weeks, is acute in nature, and is reportedly better, rating a scale of 2 out of 10. Patient states pain is manageable with NSAIDs. Review of Systems MUSCULOSKELETAL: Positive for ankle pain, although much reduced from initial injury. NEUROLOGIC: No abnormalities noted. Physical Exam Musculoskeletal Ankle: Reduced range of motion. Mild swelling. Mild muscle tenderness in the ankle. Reduced ankle flexion strength. Neurologic Consciousness, orientation, cooperation: Alert, fully oriented. Cooperative with exam. Reflexes: No abnormalities noted. Assessment 1. Right Lateral Malleolus Fracture due to sports injury Plan Care Plan (Recommendations) Cast was removed in today s visit and patient has been referred for physical therapy to improve ankle strength and range of motion. I advised patient to continue taking over-the-counter pain medications such as NSAIDs as needed for pain.

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9 EXHIBIT 5B2 Utopia University Sports Medicine Center 9727 North Morava Blvd., Utopia City, Utopia Phone: (342) Thomas, Sloane, DOB: 01/02/1997 Encounter Note 03/16/2017 Davis, Arya, M.D. This note has been signed by Davis, Arya on 03/16/ :15:21 PM Chief Complaint Sloane Thomas is a 20 year old male. He complains of severe pain in his left shoulder. History of Present Illness Full-Thickness Rotator Cuff Tear: Sloane presents for an initial evaluation of shoulder pain. Shoulder pain has been present for one day and is acute in nature. The pain began after a fall sustained during a pick-up basketball game. He states that the swelling and pain has gotten worse since the time of the incident. The pain is unbearable ; Sloane describes it as a 10+ on a 10-point scale. Review of Systems MUSCULOSKELETAL: Negative for cervicalgia and low back pain. Positive for rotator cuff pain. NEUROLOGIC: Negative for headache. Positive for numbness in extremities. Tingling in the fingers of the injured left arm. Physical Exam Musculoskeletal Head and neck: No visible or palpable abnormalities. Cervical range of motion: normal. Spine, ribs, and pelvis: Normal. Rotator Cuff: Reduced range of motion. Severe swelling. Severe muscle tenderness in the left shoulder region. Reduced left shoulder flexion. Neurologic Consciousness, orientation, cooperation: Alert, fully oriented. Cooperative with exam. MRI of Left Shoulder Region MRI shows full tear of the left rotator cuff tendons. The tear appears new, consistent with the acute nature of the injury. Assessment 1. Full-Thickness Left Rotator Cuff Tear due to sports injury Plan Care Plan (Recommendations) Treatment of a full-thickness rotator cuff tear requires surgery, scheduled for March 21, Addendum (03/21/2017): Outpatient surgery was successful. Patient was accompanied to surgical visit by parent Rory Thomas. Post-surgical care: Patient is advised to rest and immobilize shoulder to the best of his ability for two weeks, at which time patient should schedule twice-weekly physical therapy sessions. Given the severity of the injury, NSAIDs are unlikely to be sufficient for pain management. 30-day course of Vicodin HP is prescribed. Recommended dose: 1 pill every 4-6 hours as needed for pain

10 EXHIBIT 5B2 relief, maximum of 6 pills/day. No automatic refills, but will refill prescription up to 2X upon request if seems advisable. Patient must return for further extensive evaluation if pain management is still an issue after 90 days. Patient was reminded to read Vicodin HP Medication Guide drug insert. Addendum (04/12/2017): Patient requested Vicodin HP refill; granted. Addendum (05/17/2017): Patient requested Vicodin HP refill; granted; reminded must have full work-up prior to any additional refills. Addendum (06/2/2017): Patient left voic in general mailbox, requesting a Vicodin HP refill. Current prescription should last until appointment on June 19. Will reevaluate situation at that time. Addendum (06/19/2017): Patient was no-show for 10am appt.