Detailed Treatment Process
9 min read
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 pain more than four months ago without any obvious trigger. There was no fever, chills, or numbness in the limbs. The lower limb felt weak and unsteady during walking, but there was no locking of the knee. Conservative treatment had been tried, with possible partial improvement. More recently the left knee became more swollen and painful, and climbing stairs was difficult. An MRI at an outside hospital showed a tear of the posterior horn of the medial meniscus of the left knee, synovitis with a small amount of fluid inside the joint capsule, and a popliteal cyst. The patient was admitted for further evaluation and treatment under the diagnosis of left knee meniscal injury. Throughout the illness, the patient remained in good spirits, with normal appetite, sleep, and bowel and bladder function, and no fever. Body weight was stable. Physical Examination: T: 36.5℃ P: 80 beats/min R: 16 breaths/min BP: 130/80 mmHg No obvious atrophy of the left quadriceps. Mild swelling of the left knee with marked medial tenderness. Normal skin temperature. Knee range of motion essentially normal. Patellar tap test negative, anterior drawer test negative, posterior drawer test negative, Lachman test negative, valgus stress test negative, varus stress test negative, McMurray test negative, Pivot Shift test negative. Distal circulation, sensation, and motor function normal. Main laboratory and imaging findings during hospitalization (with dates and report numbers where available): 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 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 μmol/L Prealbumin 251 mg/L Cholylglycine 1.6 mg/L α1-Antitrypsin 100.4 mg/dL Serum amyloid A 3.10 mg/L Urea 5.30 mmol/L Creatinine 48 μmol/L Estimated glomerular filtration rate 101 Estimated glomerular filtration rate 140 Uric acid 475 μmol/L Retinol-binding protein 31 mg/L Cystatin C 0.84 mg/L Complement C1q 176 mg/L Glucose 4.95 mmol/L Chloride 109.0 mmol/L Total calcium 2.36 mmol/L Magnesium 1.01 mmol/L Phosphorus 1.13 mmol/L Carbon dioxide combining power 28 mmol/L The following is the discharge summary Section Office: Orthopedics Admission Date: July 1 Discharge Date: July 9 Admission Diagnosis: Left meniscus injury Discharge Diagnosis: Left meniscus injury Brief History on Admission: The patient developed left knee pain more than four months earlier without any obvious trigger. There was no fever or chills, and no numbness in the limbs. The lower limb felt weak during walking, but there was no knee locking. Conservative treatment had been tried previously, with possible mild improvement. More recently, swelling and pain in the left knee worsened, and climbing stairs became difficult. An MRI at another hospital showed a tear in the posterior horn of the medial meniscus of the left knee, synovitis with a small amount of fluid in the joint capsule, and a popliteal cyst. The patient was admitted for further evaluation and treatment under the diagnosis of left meniscus injury. During the course of the illness, the patient maintained good spirits, normal appetite, and normal sleep, with regular bowel and bladder function and no fever. There was no significant recent weight change. Physical Examination Summary: T: 36.5°C P: 80 beats/min R: 16 breaths/min BP: 130/80 mmHg There was no obvious atrophy of the left quadriceps muscle. The left knee showed mild swelling with obvious tenderness on the medial side. Skin temperature was normal. Range of motion of the left knee was not significantly limited. Floating patella test (-), anterior drawer test (-), posterior drawer test (-), Lachman test (-), valgus stress test (-), varus stress test (-), McMurray test (-), and Pivot Shift test (-) were all negative. Peripheral circulation, sensation, and motor function were normal. Major Laboratory and Special Examination Results During Hospitalization (laboratory tests, X-ray/CT/MRI, pathology, etc., with dates and examination numbers noted where applicable) 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-Glutamyl transferase (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 μmol/L Prealbumin 251 mg/L Glycocholic acid 1.6 mg/L α1-Antitrypsin 100.4 mg/dL Serum amyloid A 3.10 mg/L Urea 5.30 mmol/L Creatinine 48 μmol/L Estimated glomerular filtration rate 101 Estimated glomerular filtration rate 140 Uric acid (UA) 475 μmol/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 Jaundice index negative Hemolysis index negative Lipemia index negative Total bilirubin (TBIL) 20.7 μmol/L Direct bilirubin (DBIL) 5.6 μmol/L Chest X-ray: Increased lung markings in both lungs, no obvious active lesions. ECG: Sinus rhythm with T-wave changes. Course and Treatment (including surgery name, surgery date, blood transfusion type and volume): After admission, the patient completed the necessary examinations and had no contraindications to surgery. On July 3, under general anesthesia, the patient underwent left knee arthroscopy with exploration, debridement, meniscus suture repair. Postoperatively, treatment focused on promoting blood circulation, reducing swelling, and providing symptomatic pain relief, along with guidance on appropriate functional exercises. The patient’s general condition was good at discharge. Treatment Outcome: Cured Condition at Discharge: The patient was in good general condition with no specific complaints. Physical examination showed the affected limb swelling had subsided, the surgical wounds showed no redness, swelling, or exudation and had healed well, and distal sensation, motor function, and circulation in the affected limb were normal. Post-Discharge Medications and Recommendations: 1. Follow-up in the orthopedic outpatient clinic; seek prompt medical attention if fever develops, or if there is wound redness, swelling, exudation, or progressive swelling of the affected limb. 2. Avoid weight-bearing and strenuous activity on the affected limb for at least three months; perform appropriate functional exercises. 3. Discharge medications: Celecoxib capsules, 12 capsules, once daily, oral Sodium hyaluronate injection (intra-articular), 4 doses, once, for intra-articular use Diosmin tablets, 60 tablets, once daily, oral Completion Date: July 9
The above discharge summary does not record the patient’s age, which violates basic documentation standards. After discharge, the patient continued to experience pain when walking. The following is an MRI of the knee performed at another hospital 10 days after discharge. Examination Site and Name: Left knee joint MRI plain scan Examination Method: Knee joint MRI plain scan Radiological Findings: The bones comprising the left knee joint showed normal morphology with no abnormal signal shadows within the bone. The medial joint space of the left knee was slightly narrowed, with rough articular cartilage surfaces. There was a small amount of fluid in the left knee joint cavity and within the joint capsule. A linear high-signal shadow was seen in the posterior horn of the medial meniscus, extending to the inferior articular surface margin. The lateral meniscus showed normal morphology and signal. The anterior and posterior cruciate ligaments and medial and lateral collateral ligaments showed normal morphology and signal. The joint synovium was mildly thickened. Radiological Diagnosis: 1. Tear of the posterior horn of the medial meniscus of the left knee; 2. Mild synovial thickening of the left knee joint; 3. Small amount of fluid in the left knee joint cavity and joint capsule. Examination Date: 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 $5,000 per session, which is not covered by medical insurance.