Case Study 1 - Copy
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Dallas County Community College *
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MISC
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Medicine
Date
Apr 3, 2024
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docx
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Case Study/Medical Record Analyses
Medical Record 6.1
Section 1: Put your answer to the multiple-choice questions mini medical record here:
1. A
2. D
3. E
4. D
5. E
6. C
7. A
Medical Record 6.2
1 Below are medical terms used in this record you have not yet encountered in this text. Please
use an online medical dictionary or textbook to define these terms.
malleolus: An expanded projection or process at the distal end of the fibula or tibia at the level of
the ankle.
oblique: A fracture that extends in an oblique direction. Slanted.
sterile: Free from living organisms and especially pathogenic microorganisms
2 Briefly describe the preoperative diagnosis for Ms. Toohey. After successful general anesthesia, the right lower extremity was prepped and draped in a sterile
fashion. A pneumatic tourniquet was used in the case at 300 mm Hg (mercury) for 51 minutes. 3. Put the following operative steps in correct order by numbering them 1 to 10.
1
8 x-ray of the screws that were too long.
3 incisions on the outer side of the ankle
5 plates placed onto fibula.
10
sewing the incisions.
9
x-ray of satisfactory screw position
6
towel clips positioned.
2 removal of medial hematoma
4
removal of lateral hematoma
7
placements of screw into lower tibia
1
incision on the inner side of the right ankle
4.
In this operation the surgeon redid one step after using a diagnostic procedure to check
whether that step was as effective as possible. Explain what Dr. Rodriguez changed and
why.
X-Ray was repeated. The fist x-ray, the laterally screw were too long, and the second R-ray was to revel the if the position was satisfactory. 5. Describe the fracture line:
Large transverse medial malleolar fracture. 6.
When Dr. Rodriguez examined the ankle after making the first incision, he found a problem
he could not and did not repair. What had been destroyed in Ms. Toohey’s injury?
The articular cartilage destruction and damage on the talus.
2
7.
Which of the following actions did not occur in this operation? Use the highlighter function
to select your answer.
a.
washing the wound with antibiotic
b.
taping the fracture line
c.
drilling holes in the bone
d.
stapling the skin closed
8.
Describe Ms. Toohey’s condition when transferred to PAR after the operation:
The patient tolerated the procedure well and was transferred to the recovery room with stable vital signs. Medical Record 6.3
1. Below are medical terms used in this record you have not yet encountered in this text. Please
use an online medical dictionary or textbook to define these.
Eburnation: a diseased condition in which bone or cartilage is eburnated
Lipping: outgrowth of bone in liplike form at a joint margin
Discogenic: originating in an intervertebral disc: produced by factors (such as herniation or
Deterioration) occurring in an intervertebral disc. 2. What phrase in the report indicates more than one x-ray was taken?
X-ray report: Multiple views reveal no evidence of fracture. 3. Describe the three diagnoses Dr. Volz makes:
1-
Slight lumbar spondylosis with hypertrophic
2-
Grade I spondylolisthesis L’5 (S1) / L5 LEFT
3-
Slight dextroscoliosis in the lumbar 3
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