Insurance Cigna Date of Birth- 08/09/1949. Preferred Language - English Emergency Contact Mary J. (Wife) Phone (555)

Transcription

1 Visit Type Ambulatory Surgery Patient Name Marquis J. Date of Visit - 2/1/2017 Time 12:15 p.m. Insurance Cigna Date of Birth- 08/09/1949 Medical Record # Sex Male Marital Status - Married Preferred Language - English Emergency Contact Mary J. (Wife) Phone (555) Reason for Visit Right total knee arthroplasty stiffness Referred by Mark S., MD Procedure to be Completed Today Manipulation under anesthesia, right knee Surgeon Greg M., MD.

2 HISTORY CC: Bilateral knee pain HPI: This year old male complains of severe pain in his knees. The right knee is worse than the left. He has been treated by his family doctor with oral nonsteroidal medications. He has had physical therapy, and well as injections. He feels that he is limited in his daily activities. He is worse with stair climbing, squatting, weight bearing. He does not use any kind of aid for ambulation. He has had right knee arthroscopy in the past at HITNOTS Health. PMH: Noncontributory SURGICAL HISTORY: Cataract, knee arthroscopy and arthrotomy, tonsillectomy. FAMILY HISTORY: Positive for cancer, diabetes and hypertension. He has had no recent fever, chills, chest pain SOB or infection. Electronically signed by Greg M., MD on 2/1/2017 at 9:30 am

3 PHYSICAL VITAL SIGNS: Stable. He is 70 inches tall, 270 lbs. HEENT: He is atraumatic. NECK: Supple CHEST: Clear to auscultation HEART: Regular rate and rhythm ABDOMEN: Soft. Bowel sounds present. No mass is palpated. EXTERMITIES: Tenderness over the medial and lateral joint lines of the right knee. Scar is present above the knee. He flexes to 90 extends to 0 at the left knee. X-ray shows severe osteoarthritis with varus about the knees, left worse than right. X-rays show severe arthritis. PLAN OF CARE: We discussed risks, benefits, and alternatives to knee replacement. He would like to proceed. He would like to have a right total knee replacement. All of his questions regarding the surgery were answered and surgery is planned. Electronically signed by Greg M., MD on 2/1/2017 at 9:30 am

4 AMBULATORY SURGERY PATIENT NAME Marquis J. DOB 8/9/1949 MR# SEX - Male DATE: 2/1/2017 TIME IN: 12:15 PM TIME OUT: 12:59 PM PREOP DX: Status post total knee arthroplasty with adhesive capsulitis POSTOP DX: Status post total knee arthroplasty with adhesive capsulitis PROCEDURE: Manipulation under anesthesia, right knee SURGEON Greg M. MD COMPLICATIONS: None ESTIMATED BLOOD LOSS: None DESCRIPTION OF PROCEDURE: The patient had identified the right knee as that requiring surgery 6 weeks status post total knee arthroplasty on the right. He has had progressive loss of motion since this surgery and his flexion only to 50 degrees come to full extension. His wound is healed benign. No fever or chills. We discussed risks, benefits, alternatives to manipulation under anesthesia. The patient understands and would like to proceed with the procedure. Patient was brought to the OR, given general anesthesia. Under anesthesia, he was made comfortable. Needed extension and flex to 50 degrees with gentle manipulation, adhesions were released until flexion was 110 degrees, which seemed to be the antral endpoint in this large individual. The wound remained benign, healed from previous surgery. The knee is stable and end motion is 0 to 110 degrees with flexion falling to 90 degrees with gravity. The patient was then taken to recovery in satisfactory condition. There were no complications. Electronically signed by Greg M., MD on 2/1/2017 at 4:30 pm.

5 SURGICAL PATHOLOGY REPORT PATIENT NAME Marquis J. DOB 8/9/1949 MR# SEX - Male PHYSICIAN Greg M. MD DATE: 2/1/2017 SPECIMENS Bone and tissue, right knee CLINICAL DIAGNOSIS Osteoarthritis, right knee FINAL PATHOLOGICAL DIAGNOSIS Bone and Tissue, right knee, received from lab. Changes grossly consistent with osteoarthritis. (Gross Only). GROSS Received fresh labeled bone and tissue right knee is an 8.5 x 8.0 x 5.0 cm aggregate of articular knee bone and soft tissue. The articular surface is granular tan-red with focal eburnation and mild peripheral osteophyte formation. Gross exam only. Electronically signed by Phyllis M. MD, Pathologist, HITNOTS HEALTH on 2/1/2017 6:05 pm.

6 PRE-OPERATIVE CHECKLIST Date - 2/1/2017 Time 9:35 am Items to Check Yes No N/A Explain No Answer Initials Pre-op Teaching Seen by Anesthesia ID Band Fall Precaution Band Allergy List / Band N/A Operative Consent H&P EKG CBC Previous Record, if ordered Dentures Removed N/A Eye glasses/ Contacts Removed Hearing Aid Removed N/A Jewelry Removed Hairpieces / Pins Removed Body Piercing Removed N/A N/A Electronically signed by Diane W., RN at 9:45 am on 2/1/2017 INFORMED CONSENT FOR SURGICAL PROCEDURE

7 It is your doctor s obligation to provide you with the information you need in order to decide whether to consent to the surgery or special procedure that your doctors have recommended. The purpose of this form is to verify that you have received this information and have given your consent to the surgery or special procedure recommended to you. You should be involved in any and all decisions concerning the surgical procedure. Sign this form only after you understand the procedure, the risks, the alternatives, the risks associated with the alternatives, and all of your questions have been answered. Please initial and date directly below this paragraph indicating your understanding of this paragraph. MJ Patient's Initials or Authorized Representative Date Your doctors have recommended the following operation or procedure - : Manipulation under anesthesia, right knee I, Marquis J. hereby authorize Greg M., MD. and any associates or assistants the doctor deems appropriate, to perform : Manipulation under anesthesia, right knee The risks and benefits associated with the procedure have been explained to me. However, I understand there is no certainty that I will achieve these benefits and no guarantee has been made to me regarding the outcome of the procedure(s). I also authorize the administration of sedation and/or anesthesia as may be deemed advisable or necessary for my comfort, wellbeing and safety. The risks and possible undesirable consequences associated with the procedure have been explained to me including, but not limited to, blood loss, transfusion reactions, infection, heart complications, blood clots, loss of or loss of use of body part or other neurological injury or death. If your doctor determines that there is a reasonable possibility that you may need a blood transfusion as a result of the surgery or procedure to which you are consenting, your doctor will inform you of this and will provide you with information concerning the benefits and risks of the various options for blood transfusion, including pre-donation by yourself or others. You also have the right to have adequate time before your procedure to arrange for pre-donation, but you can waive this right if you do not wish to wait. Transfusion of blood or blood products involves certain risks, including the transmission of disease such as hepatitis or Human Immunodeficiency Virus (HIV), and you have a right to consent or refuse consent to any transfusion. You should discuss any questions that you may have about transfusions with your doctor.

8 INFORMED CONSENT FOR SURGICAL PROCEDURE Page 2. - In permitting my doctor to perform the procedure(s), I understand that unforeseen conditions may be revealed that may necessitate change or extension of the original procedure(s) or a different procedure(s) than those already explained to me. I therefore authorize and request that the abovenamed physician, his assistants, or his designees perform such procedure(s) as necessary and desirable in the exercise of his/her professional judgment. The reasonable alternative(s) to the procedure(s) have been explained to me. I hereby authorize my doctor to utilize or dispose of removed tissues, parts or organs resulting from the procedure(s) authorized above. I consent to any photographing or videotaping of the procedure(s) that may be performed, provided my identity is not revealed by the pictures or by descriptive texts accompanying them. I also consent to the admittance of students or authorized equipment representatives to the procedure room for purposes of advancing medical education or obtaining important product information. As required by the Safe Medical Device Act, I consent to the release of my name, address, and social security number to the manufacturer of any medical device I receive. By signing below, I am indicating that I have had an opportunity to ask the doctor all questions concerning risks, alternatives, and risks of those alternatives. Date - 2/1/2017 Signature Marquis J. AUTHORIZED REPRESENTATIVE: The Patient/Authorized Representative states that he/she understands this information and has no further questions. Electronically signed on 6/2/2016 at 5:03 pm CERTIFICATION OF PHYSICIAN: I hereby certify that the facts, risks, the risks associated with the alternatives of the procedure(s) described in this form have been discussed with the individual granting consent. In addition, I have answered any questions asked of me. Greg M., MD. HITNOTS Health. Electronically signed on 2/1/2017

9 DISCHARGE INSTRUCTIONS This form provides you with initial instructions about your medical care in the ambulatory surgery department of HITNOTS Health. Keep this form with you in case you need further medical care. Dx Osteoarthritis, right knee Procedure - Manipulation under anesthesia, right knee Physical Therapy three times per week. Activity as tolerated. Darvocet N100, every 4-6 hours, prn for pain. Return to the office in 3 weeks for follow-up. Call physician s office for any problems or questions. I have received a copy of the Discharge Instruction Sheet Marquis J. patient. Electronically signed by Marquis J. on 2/1/2017 at 4:30 pm. Electronically signed by Greg M., MD on 2/1/2017 at 4:45 pm. This medical record information is totally fictitious. Any similarity to a real person, living or dead, is incidental. The medical content of this record may not be totally clinically accurate, and therefore should not be used as an example for diagnoses or procedures.