Orthopaedic Surgeon's note (Ben custom)

Chief Complaint: Right knee pain and swelling after a fall. Subjective: - Patient reports a fall while skiing two weeks ago, resulting in immediate right knee pain and swelling. Pain is described as sharp, localized to the medial aspect of the knee, and exacerbated by weight-bearing and twisting motions. Patient reports previous injuries, but none to the right knee. - Past medical history is significant for hypertension, well-controlled with medication. No prior orthopaedic surgeries. - Current medications include lisinopril for hypertension and ibuprofen as needed for pain. - Patient is a 45-year-old active individual, works as a software engineer, and enjoys skiing and hiking. - No known drug allergies. Objective: - Pre-operative exam findings: - Cardiac: Regular rate and rhythm - Lungs: Clear to auscultation bilaterally General Exam: - Constitutional: Healthy appearing, no acute distress - Psychiatric: Active and alert, normal mood and affect - Gait and Station: Normal gait, patient is walking without assistive devices - **Part of body examined:** Right knee - Inspection: Skin intact. Mild swelling and ecchymosis noted medially. - Palpation: Tenderness to palpation along the medial joint line and medial collateral ligament. - Range of motion: Limited range of motion due to pain and swelling; flexion to 90 degrees. - Strength: 5/5 strength with all testing. - Stability: Mild medial joint line laxity noted with valgus stress testing. - Special Test: Positive McMurray's test and valgus stress test at 30 degrees. - Neurovascular examination findings: Distal pulses intact, no sensory deficits. - Xrays: X-rays taken on 20 October 2024 at local imaging center, AP, lateral, and skyline views of the right knee. Findings: No acute fracture identified. - Other studies: MRI of the right knee performed on 27 October 2024, revealing a complete tear of the medial meniscus and a partial tear of the medial collateral ligament. Assessment & Plan: 1. Right Knee - Medial Meniscus Tear and MCL Sprain - Assessment: Diagnosis of a complete tear of the medial meniscus and a partial tear of the medial collateral ligament based on clinical examination and MRI findings. - Differential diagnosis: Consider other causes of knee pain, such as osteoarthritis, ligamentous injuries, and patellofemoral pain syndrome. - Investigations planned: None - Surgical treatment planned: Arthroscopic meniscectomy and MCL repair. The patient has been informed of the risks and benefits of the procedure. - Non-surgical treatment options: Patient has been offered the option of non-operative management with bracing, physical therapy, and activity modification, but the patient has elected for surgical intervention. - Pre-operative preparation: Patient to discontinue ibuprofen one week prior to surgery. Pre-operative education provided regarding the procedure, risks, and post-operative care. - Post-operative care plan: Patient will be discharged home the same day. Patient will be seen in the office for a follow-up appointment in two weeks. Patient will be instructed to follow up with physical therapy for rehabilitation. - Relevant referrals: Physical therapy referral provided. Follow-up: 2 weeks Xrays needed at next visit: PRN Additional Notes: - Patient education on the diagnosed condition, surgical procedures, potential complications, and the importance of rehabilitation and adherence to post-operative care. - Instructions for pre-operative and post-operative care, including activity restrictions, wound care, signs of complications to watch for. - Any specific patient or family concerns addressed during the consultation. ICD-10 Code: M23.23 - Derangement of meniscus, medial, current injury, right knee. Justification: This code accurately reflects the diagnosis of a medial meniscus tear in the right knee.