Patient Status Report

PROCEDURE IN DETAIL: The patient was brought into the operating room, after satisfactory anesthesia, was placed in the left lateral dicubitis position. The right hip was prepped and draped. A previous made incision was reopened over the greater trochanter and carried down to Illiotibial (IT) band. The IT band was opened in the direction of the skin incision. The anterior 1/3 of the gluteus medius/minimus group was reflected off the trochanter over to the anterior brim of the pelvis. The hip was dislocated. The femoral component was easily removed. It was loose in the cement. The polyethylene was loose and easily removed. There was a lot of cement in and around the acetabulum. We debridement most of this. There was a wired mesh plug that went medially into the pelvis that was left in place. There was also one in the ishium that was quite stable and it was left in place. There was a large defect in the medial wall of the acetabulum about the size of a silver dollar.

Based on the progress report dated 03/28/16 by Dr. Bakhos, the patient presents for follow-up of his right knee

HPI: S.J. is a 67 y/o Caucasian male with a history of left hip pain for two years. He has difficulty walking due to left hip pain and utilizes a cane, can walk five blocks, climbs stairs leading with the right leg. He denies any surgeries on the left lower extremity. He sought physical therapy, but he does not feel that it is improving his pain but does believe it is improving his strength. He is scheduled for a left total hip arthroplasty due to the progression of severe osteoarthritis of the left hip as confirmed by a pelvic x-ray and MRI of the lower extremity without contrast. S.J. has taken various medications that are listed on the current medication section of this note.

Manual muscle testing of the left glenohumeral joint with flexion, abduction and external rotation is 4/5. Patient is with limited use of the left upper extremity and has slow progress noted with precautions of pacemaker limiting aggressive stretching. Plan is to progress with ROM and mobility strength.

Based on the latest medical report dated 12/23/16, the patient is noted to be approximately one year status most recent left knee arthroscopy. The patient is also status post anterior cruciate ligament reconstruction of the left knee, several years ago. The patient is now two years status post revision anterior cruciate ligament reconstruction of the right knee. The patient complains of some discomfort in the right knee.

Based on the progress report dated 03/28/16, the patient complains of pain to his lumbar

DOI: 4/29/2015. Patient is a 48-year-old female occupational therapist who sustained injury while engaged in an exercise with her patient. Per OMNI entry, patient has had several surgeries to her right hip on 02/02/16, 03/11/16 and 05/09/16. Patient is using crutches and is slated for hardware removal in 01/2017.

Based on the progress report dated 12/16/15, the patient reports that the pain remains in the low back and bilateral shoulders. The low back pain radiates to the bilateral lower extremities and is associated with numbness and tingling. He has worsening leg symptoms. He has not yet been authorized for his lumbar ESI. Surgery is pending for the left shoulder.

Per the medical report dated 09/08/16 by Dr. Livermore, the patient has worsening pain over the left leg, numbness of the left foot and weakness in the left leg.

Per the QME report dated 08/21/14 by Dr. Hurria, the patient has a calculated total whole person impairment grating of 33%. Diagnoses include arthritis of both hips, status post right total hip replacement, cervical/lumbar sprain, radiculopathy to both upper and lower extremities, right cubital tunnel syndrome and impingement of both shoulders. Future medical treatment includes decompression of both shoulder, transfer of the anterior ulnar nerve

MRI of the right knee without contrast performed on 12/10/15 revealed extensive contusion/nondisplaced fractures of the femur, tibia and fibular head, partial/subtotal tear of the anterior cruciate ligament (ACL) and suprapatellar and intra-articular joint fluid. No acute medial or lateral meniscal tear is noted.

DOI: 2/10/2011. Patient is a 56-year-old male controller who sustained a knee injury when he hit his knee when he turned while sitting on a chair. Per operative reports, the patient is status post right knee diagnostic arthroscopy with chondroplasty and removal of scar tissue on 12/14/2012, right knee arthroscopy and trochlear microfracture, partial medial meniscectomy and plica excision on 02/28/2012, and right total knee arthroplasty on 11/30/15.

The patient has reduced adduction of 20 degrees compared to right hip. In addition, the patient has a positive click when the hip is flexed and adducted with reproduction of significant pain to the left hip. In addition, the patient has a positive anterior posterior glide test as well as a lateral glide test as well. At this point, examination of the left hip is consistent with having a recurrent left labral tear. Another MRI is needed to evaluate the further labrum if he has a further labral tear, if he needs to be re-attached, or if he needs a decompression on the acetabular site or the femoral site whether the patient may also have a femoral acetabulum impingement as well. MD opined that MR arthrography will determine further management of the left hip.

Based on the medical report dated 05/02/16, the patient states that he is experiencing more pain in his left shoulder on this visit than he has in a while. He reports relief with the steroid injection. He continues to attend PT 3 times a week. He states that he feels some improvement with PT.

As per progress report dated 8/05/15, the patient is being seen for chronic right ankle pain and chronic right foot pain. Her current medications include Cymbalta 60 mg, Relafen