Detailed Treatment Process
The following is the discharge summary Section Office: Orthopedics In Time: July 01 Out time: July 09 Cause: Meniscal injury (left) Diagnosis: Meniscal injury (left) Brief History: The patient developed left knee joint pain more than 4 months ago without obvious inducement. There was no fever, chills, or limb numbness. The lower limb felt soft and weak when walking, with no knee locking. Conservative treatment was given, and symptoms may have improved somewhat. Recently, swelling and pain in the left knee worsened, with difficulty going up and down stairs. The patient visited an outside hospital, where MRI suggested tear of the posterior horn of the medial meniscus of the left knee, synovitis of the left knee joint with a small amount of fluid in the joint capsule, and a left popliteal cyst. For further diagnosis and treatment, the patient was admitted via outpatient clinic with the preliminary diagnosis of "left knee meniscal injury." During the course of the disease, the patient’s spirit was fair, appetite was fair, sleep was fair, bowel and bladder function were normal, and there was no fever. There was no significant recent change in body weight. Physical Examination: T:36.5℃ P:80 beats/min R:16 breaths/min BP:130/80 mmHg No obvious atrophy of the left quadriceps femoris. The left knee joint showed mild swelling, with obvious medial tenderness. Skin temperature was normal. No obvious limitation in left knee joint movement. Patellar tap test (-), anterior drawer test (-), posterior drawer test (-), Lachmann (-), valgus stress test (-), varus stress test (-), McMurray test (-), Pivot Shift (-). Distal limb circulation, sensation, and movement were normal. Main laboratory tests and special examination results during hospitalization (lab tests, X-ray/CT/MRI, pathology, etc., with dates and report numbers noted) Basophil count 0.02 × 10⁹/L Basophil percentage 0.5% Eosinophil count 0.20 × 10⁹/L Eosinophil percentage 4.8% Hematocrit (Hct) 38.7% Hemoglobin (HGB) 126 g/L High-sensitivity C-reactive protein 0.5 mg/L Lymphocyte count 1.58 × 10⁹/L Lymphocyte percentage 38.1% Mean corpuscular hemoglobin 29.6 pg Mean corpuscular hemoglobin concentration 326 g/L Mean corpuscular volume 91.1 fL Monocyte count 0.45 × 10⁹/L Monocyte percentage 10.8% Mean platelet volume 10.4 fL Neutrophil count 1.90 × 10⁹/L Neutrophil percentage 45.8% Plateletcrit 0.17% Platelet distribution width 12.3% Large platelet ratio 28.7% Platelet count 162 × 10⁹/L Red blood cell count 4.25 × 10¹²/L Red cell distribution width 11.7% White blood cell count 4.15 × 10⁹/L Erythrocyte sedimentation rate (ESR) 2 mm/h Prothrombin time 12.60 s International normalized ratio (INR) 0.96 Activated partial thromboplastin time 36.60 s Potassium (K) 4.35 mmol/L Sodium (NA) 140.0 mmol/L Alanine aminotransferase (ALT) 29.0 u/l Aspartate aminotransferase (AST) 24.0 u/l Aspartate aminotransferase isoenzyme 9.6 U/L Alkaline phosphatase (ALKP) 45.0 u/l γ-glutamyltransferase (GGT) 23.0 u/l Total protein (TP) 68.8 g/l Albumin (ALB) 42.0 g/l Globulin 27 g/l Albumin/globulin ratio 1.6 Total bile acid 4.3 umol/l Prealbumin 251 mg/l Cholylglycine 1.6 mg/L α1-antitrypsin 100.4 mg/dL Serum amyloid A 3.10 mg/L Urea (UREA) 5.30 mmol/L Creatinine (CREA) 48 umol/l Estimated glomerular filtration rate 101 Estimated glomerular filtration rate 140 Uric acid (UA) 475 umol/l Retinol-binding protein 31 mg/L Cystatin C 0.84 mg/L Complement C1q 176 mg/L Glucose (GLU) 4.95 mmol/L Chloride (CL) 109.0 mmol/L Total calcium (CA) 2.36 mmol/L Magnesium (MG) 1.01 mmol/L Phosphorus 1.13 mmol/l Carbon dioxide combining power 28 mmol/L Icteric index negative Hemolytic index negative Lipemic index negative Total bilirubin (TBIL) 20.7 μmol/L Conjugated bilirubin (DBIL) 5.6 umol/l Chest X-ray: Increased lung markings in both lungs, no obvious active lesions. ECG: Sinus rhythm, T-wave changes. Course of Disease and Treatment (including surgery name, surgery date, blood transfusion type and volume): After admission, examinations were completed and there were no surgical contraindications. On July 03, under general anesthesia, the patient underwent "left knee arthroscopic exploration, debridement, and meniscus suture repair." Postoperatively, active treatment was given to promote circulation and reduce swelling, along with symptomatic pain relief and guidance for appropriate functional exercises. The patient is now in good general condition and is being discharged. Treatment Result: Cured Condition at Discharge: The patient’s general condition is good, with no special discomfort complaints. Physical examination: general condition fair, swelling of the affected limb has subsided, surgical wound shows no redness, swelling, or exudation, healing is good, and sensation, movement, and circulation at the distal end of the affected limb are good. Post-Discharge Medications and Recommendations: 1. Follow-up at the orthopedic outpatient clinic; seek timely medical attention if there is fever, wound redness, swelling, exudation, or persistent progressive swelling of the affected limb; 2. Prohibit weight-bearing and strenuous activity on the affected limb for at least three months, with appropriate functional exercises; 3. Discharge medications: Celecoxib capsules, 12 capsules, ONCE, oral Sodium hyaluronate injection (for intra-articular use), 4 vials, ONCE, external use Diosmin tablets, 60 tablets, ONCE, oral Date of Completion: July 09
The above discharge summary does not record the patient’s age, which violates basic documentation standards. After discharge, the patient continued to have pain while walking. The following is the knee joint MRI performed at another hospital 10 days after discharge. Examination site and name: Plain MR scan of the left knee joint Examination method: Plain MRI scan of the knee joint Radiological findings: The morphology of the bones forming the left knee joint is normal, with no abnormal signal shadows in the bone. The medial joint space of the left knee is slightly narrowed, with a rough appearance of the articular cartilage surface. There is a small amount of fluid in the left knee joint cavity and within the joint capsule. A linear high signal is seen in the posterior horn of the medial meniscus, involving the inferior articular surface margin. The lateral meniscus morphology and signal are normal. The anterior and posterior cruciate ligaments and medial and lateral collateral ligaments show normal morphology and signal. The joint synovium is thickened. Radiological diagnosis: 1. Tear of the posterior horn of the medial meniscus of the left knee joint; 2. Mild synovial thickening of the left knee joint; 3. Small amount of fluid in the left knee joint cavity and joint capsule. Examination time: September 17 Report writing time: September 17 Report review time: September 17
** Later, a doctor recommended PRP treatment for the patient, at a cost of $5000 per session, not covered by medical insurance.