Hillcrest Medical Complete Case 9

Topics: Hip replacement, Pelvis, Hip Pages: 9 (1593 words) Published: April 20, 2014
HISTORY AND PHYSICAL
Patient Name: Marilyn Sue Stone
Patient ID: 116588DOB: 01/24Age: 50Sex: F
Room No.: 181A
Date of Admission: 02/07/2012
Admitting Physician: Jessie D. Smith, MD of Orthopedics
Admitting Diagnosis: Chronic Hip Pain
HISTORY OF PRESENT ILLNESS: Patient is a candidate for a total right hip revision. She has 2 units of directed packed red blood cells. It is not autologous. She does had Hepatitis B. She has arthrogryposis. She had a right total hip replacement many years ago by Dr. Dodd at the University of Miami. She has had multiple other surgical procedures as follows. A: She had bilateral foot surgery In the remote past. B: She had left hip surgery a year ago. C: She had right foot surgery in the remote past. D: She had left foot surgery in the remote past at Hillcrest by Dr. Smith, myself. E: She had right hip surgery 28 years ago. F: She had left hip surgery 26 years ago. G: 17 years ago she had a stage 2 left hip procedure completed 15 years ago. H: She had left hip revision 12 years ago. I: Nine years ago she had a mass on the bottom of her foot removed by Dr. Shelton of Podiatry . SOCIAL HISTORY: She works in the medical field. Enjoys a healthy social life, lives alone, is single, is nulliparous. She has Hepatitis B core antibody. ALLERGIES: Patient is allergic to penicillin, codeine, secphlis sporens and Demerol. MEDICATIONS: Spironolactone 25mg, 2.5 per day, Verapamil ER 240mg, 1.5 per day. Zoloft 50mg 1.5 per day. Study drug for osteolysis Nasacort and Darvocet n100 q4h p.r.n. pain. Has taken Allegra 180mg daily, Calcium and multivitamins. REVIEW OF SYSTEMS: HEENT: WNL. CARDIOPULMONARY: No history of cardiac disease, chest pain, shortness of breath or rhythm abnormality. MUSCLOSKELTEAL: See history of present illness. (Continued)

NEUROLOGIC: History of migraine headaches, otherwise WNL.
PHYSCIAL EXAMINATION: In general the patient is a very nice 50 year old lady. She is here with her brother who is a band director. She uses to crutches to ambulate. She has a great deal of difficulty moving. Vital signs shows that she has 98% Oxygen saturation on room air. NECK: Her neck moves well and her carotid pulses is normal. BREAST: Normal without masses. CHEST: Clear to A&P. HEART: Regular rhythm S1 and S2 normal. No murmur. ABDOMEN: Soft non tender, no organamegaly. EXTREMITIES: Her wrist do not extend beyond neutral they flex 90 degrees. Her ankles do not flex or extend beyond neutral. She has built up heels. Her right hip flexes 10 degrees, abducts 10 degrees, adducts 5 degrees. Her left leg 10 degrees, abducts 10 degrees, adducts 10 degrees, she has no rotation in either hip. Both are fixed in 25 degrees of external rotation. Dorsalis pedieus and posterior tibial are normal. NEUROLOGIC: Cranial nerves 2-12are normal. ASSESTMENT: Congenital hip disease failure of right total hip replacement due to wear and tear of the acetabulum component.

______________________________________________
Jessie D. Smith, MD of orthopedics

JS:ef
T:1/25/2013
D:1/25/2013

DIAGNOSTIC REPORT #1
Patient Name: Marilyn Sue Stone
Patient ID: 116588DOB: 01/24Age: 50Sex: F
Report No.: 10-630646
Ordering Physician: Jessie D. Smith, MD
Procedure: Right hip, t fuse
Date of procedure: 07/07
There are post operative changes of a revision total hip arthoplasty. The bony acetabulum is dysplastic. The revision acetabulum and femoral component are well aligned and appear well fixed. IMPRESSION: Post operative change.

___________________________________________
Paula Reddy, MD

PR:ef
T: 07/08/2013
D: 07/08/2013

OPERATIVE REPORT
Patient Name: Marilyn Sue Stone
Patient ID: 116588DOB: 01/24Age: 50Sex: F
Date of Admission: 02/07/2013
Date of Procedure: 02/08/2013
Admitting Physician: Jerry D. Smith, MD of Orthopedics.
Surgeon: Jerry D. Smith, MD of Orthopedics
Assistant:...
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