Detailed Treatment Process
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Male, 52 years old. According to a Word document provided by the family, an outpatient blood test ordered on March 23 showed a CRP of 165.63, red blood cells 3.80 × 10¹²/L, white blood cells 10.2 × 10⁹/L, and hemoglobin 108 g/L. During that same visit the doctor prescribed celecoxib capsules (0.2 g × 6 capsules/box) × 2 boxes. The following is the discharge summary: Department: Sports Medicine Admission Date: March 25 Discharge Date: March 30 Outpatient Diagnosis: Loose body in the left knee joint Admission Diagnosis: Loose body in the left knee joint Discharge Diagnosis: Loose body in the left knee joint; gouty synovitis of the left knee joint Patient Symptoms and Signs: The patient was admitted with a one-month history of left knee pain accompanied by limited mobility. Physical Examination: The knee had a normal appearance with no varus or valgus deformity. The left knee was swollen with mildly elevated skin temperature. Posterior patellar impingement sign (−), Shelf sign (−), apprehension sign (−), patellar mobility (−), joint line tenderness (−), McMurray test negative. Left knee flexion was mildly limited. No varus or valgus instability. Lachman test (−), ADT (−), PDT (−), pivot-shift test (−), compartment tenderness (+), no rotational instability. Thigh circumferences were equal. No hamstring tightness. Knee extension and flexion strength tests were normal. Investigation Results: Preoperative blood work including complete blood count, coagulation panel, liver and kidney function, electrolytes, fasting glucose, hepatitis B and C serology were essentially normal. Special Investigations: Preoperative electrocardiogram and other tests were essentially normal. Clinical Course: After admission, further investigations were completed and symptomatic treatment given. With no obvious surgical contraindications, arthroscopic removal of the loose body from the left knee joint with joint debridement was performed under general anesthesia on March 29. The procedure went smoothly with approximately 10 ml blood loss and no transfusion. The patient returned to the ward in stable condition and received anti-infective and symptomatic care. Postoperative Instructions: Monitor vital signs, wound bleeding, and neurovascular status of the affected limb. Current Status: The patient was in good general condition with no complaints. The dressing was dry with no redness or swelling around the incision, which appeared satisfactory. He was discharged and advised to continue rehabilitation at a local or lower-level hospital. Discharge Orders: 1. Change wound dressing every 3 days; remove sutures at 2 weeks. 2. Attend regular specialist outpatient follow-up; return immediately if condition changes. 3. Take discharge medications to support recovery and perform functional exercises on the affected limb. 4. Abstain from smoking and alcohol for six weeks after discharge. 5. Seek prompt care at the relevant clinic for any hypertension, diabetes, coronary heart disease, or other conditions. Outcome: Cured March 30 Page 3 of the inpatient billing statement listed 6 boxes of etoricoxib (60 mg × 5 tablets/box). The family stated this was the discharge medication, taken as one tablet daily according to the temporary orders. Because the patient later died, the family obtained copies of additional medical records. The following is the urinalysis report: Department: Sports Medicine Ward: Sports Medicine Sample Type: Urine Clinical Diagnosis: Loose body in the left knee joint Item, Result (Reference Range) Color: pale yellow (pale yellow) Turbidity: clear (clear) White blood cells: 8/μl (0~25/μl) Red blood cells: 96↑/μl (0~23/μl) Epithelial cells: 5/μl (0~31/μl) Small round epithelial cells: 0/μl (0~2/μl) Casts: 0/μl (0~1/μl) Pathological casts: negative (negative) Sperm: negative (negative) Mucus: negative (negative) Yeast-like organisms: negative (negative) Red blood cell morphology: mixed (negative) Crystals: negative (negative) Conductivity: 8.40 mS/cm (3.00~38.00 mS/cm) Specific gravity: 1.011 (1.003~1.030) pH: 5.0 (4.6~8.0) Leukocyte esterase: negative (negative) Occult blood: +++ (negative) Protein: ++ (negative) Nitrite: negative (negative) Glucose: negative (negative) Ketones: negative (negative) Urobilinogen: negative (negative~weak positive) Bilirubin: negative (negative) Urine microalbumin/creatinine: ++ (negative; + microalbuminuria; ++ overt albuminuria) Sampling Date: March 25 Submission Date: March 26 Report Date: March 26 Print Date: April 19 The following is the lower extremity vascular color Doppler ultrasound report: Ward: Sports Medicine Clinical Diagnosis: Loose body in the left knee joint Sites Examined: Lower extremity deep veins and arteries Ultrasound Findings: Bilateral lower extremity arteries showed normal courses with occasional discontinuity of the intima but no significant thickening (IMT approximately 0.7–1 mm). Several 0.5 mm hyperechoic foci were noted within the arteries. Color flow filling was good without obvious defects, no severe stenosis, and spectral waveforms showed diastolic reversal with velocities largely within normal limits. The left calf muscular vein measured 5.0 mm in diameter, contained hypoechoic material with no detectable flow signal, and did not compress with probe pressure. Surrounding collateral vessels were not prominent. Right lower extremity deep veins had normal diameters, no abnormal intraluminal echoes, complete compressibility, and continuous color flow without defects. The proximal femoral vein showed good respiratory variation with no evidence of embolism. Impression: Mild bilateral lower extremity arterial sclerosis Left calf muscular vein thrombosis Report date: March 26
Department: Sports Medicine Ward: Sports Medicine Specimen type: Serum Outpatient diagnosis: Left knee joint loose body Item, Result (Reference range) Total protein 61.1 (60.0~80.0 g/L) Albumin 26.9↓ (35.0~55.0 g/L) A/G ratio 0.8↓ (1.3~2.5) ALT 19 (0~65 U/L) AST 14 (8~37 U/L) Mitochondrial AST 3.6 (0.0~15.0 U/L) ALP 131↑ (15~112 U/L) GGT 75↑ (0~50 U/L) Cholinesterase 181↓ (203~460 U/L) Total bilirubin 5.9 (0.0~18.0 μmol/L) Direct bilirubin 2.7 (0.0~6.0 μmol/L) Total bile acids 2.5 (0.0~10.0 μmol/L) Prealbumin 169↓ (200~400 mg/L) Urea 29.4↑ (2.5~6.4 mmol/L) Creatinine 583.2↑ (53.0~115.0 μmol/L) Uric acid 774↑ (210~430 μmol/L) Retinol-binding protein 94↑ (30~70 mg/L) Cystatin C 4.16↑ (0.00~1.00 mg/L) eGFR-EPI 8.74↓ (ml/min/1.73 m²) Total cholesterol 4.27 (2.80~5.90 mmol/L) Triglycerides 0.70 (0.45~1.81 mmol/L) HDL 0.94 (0.90~1.68 mmol/L) LDL 2.75↓ (2.84~4.10 mmol/L) Apolipoprotein A-1 0.96↓ (1.04~2.02 g/L) Apolipoprotein B 0.77 (0.66~1.33 g/L) Lipoprotein(a) 38.9↑ (0~30.0 mg/dL) Apolipoprotein E 2.86 (2.90~5.30 mg/dL) APOA/APOB 1.25↓ (1.48~2.28) Sampling date: March 25 Testing date: March 26 Report date: March 26 Print date: April 19
The following is the coagulation function report. Department: Sports Medicine Ward: Sports Medicine Specimen type: Plasma Clinical diagnosis: Left knee joint loose body Note: Drawn early next morning. Item, Result (Reference range) Fibrinogen 3.62 g/L (2.00~4.00 g/L) Prothrombin time 13.3 seconds (11.0~14.0 seconds) INR 1.16↑ (0.82~1.15) APTT 28.4 seconds (20.0~40.0 seconds) Thrombin time 18.2 seconds (13.0~21.0 seconds) D-dimer 6.19 mg/L FEU (0.00~0.50 mg/L FEU) Fibrin (ogen) degradation products 20.1↑ mg/L (0.0~5.0 mg/L) Antithrombin III activity 82.1% (75.0~125.0%) Note: ↑ elevated, ↓ decreased Sampling date: March 29 15:52:12 Testing date: March 30 10:01:34 Report date: March 30 13:15:30 Print date: April 19 16:15:36
The following is the electrolyte report. Department: Sports Medicine Specimen type: Serum Clinical diagnosis: Left knee joint loose body Item, Result (Reference range) Serum potassium 4.65 mmol/L (3.50~5.50 mmol/L) Serum sodium 143 mmol/L (135~145 mmol/L) Serum chloride 108.5↑ mmol/L (95.0~105.0 mmol/L) CO₂ 16.8↓ mmol/L (21.0~31.0 mmol/L) Calcium 2.07↓ mmol/L (2.08~2.60 mmol/L) Magnesium 0.97 mmol/L (0.65~1.05 mmol/L) Phosphorus 1.75↑ mmol/L (0.80~1.60 mmol/L) Blood glucose 5.28 mmol/L (3.90~5.80 mmol/L) Albumin 39.4↓ % (55.8~66.1%) α1 globulin 9.7↑ % (2.9~4.9%) α2 globulin 13.1↑ % (7.1~11.8%) β1 globulin 6.1% (4.7~7.2%) β2 globulin 9.9↑ % (3.2~6.5%) γ globulin 21.8↑ % (11.1~18.8%) This result has been rechecked!!! Note: ↑ elevated, ↓ decreased Sampling date: March 25 17:14:42 Testing date: March 26 08:09:15 Report date: March 26 09:39:19 Print date: April 19
Review of temporary orders shows no blood routine tests were performed during the hospital stay. The family’s written account notes pain on April 2, April 5, April 12, and April 16 that prevented sleep. The April 16 description also mentions pain, sweating, pale face, and general weakness. On April 15 the patient returned to the operating surgeon for follow-up. The medical record states: Chief complaint: Left knee post-surgery. History: Left knee post-surgery. Physical examination: Wound healing well. Swelling. Tests: Blood routine + C-reactive protein. Treatment: Joint aspiration (family description indicates 200 cc of fluid was drawn in the second-floor treatment room). Prescription: Etoricoxib 3 boxes (60 mg × 5 tablets/box). Regarding April 17, the day of death, the family’s written description states: At 8 a.m., the patient got up with little energy and leaned against the bed. He said, “It still hurts; this surgery has caused pain for too long and feels particularly uncomfortable.” Around 2 p.m., he was taken downstairs in a wheelchair to sunbathe. He looked at the river with little spirit and did not want to talk. Around 4 p.m. he returned home, sat on the bed, sweated profusely, and said, “I feel unwell; the operated leg feels especially heavy and I can’t turn over easily.” He asked for a small pillow to prop himself up for comfort. Shortly afterward his complexion worsened. At 17:34 contact was made with the hospital head nurse, who replied, “Hemoglobin is very low—severe anemia. He needs a blood transfusion or iron supplements.” The family replied they would go to the pharmacy. They arranged to bring the patient to the emergency department immediately for transfusion. At 17:42 he said, “I have no strength,” his voice weak. Soon the family sensed something was seriously wrong and called an ambulance. He sweated heavily, said he felt terrible, and had difficulty breathing. He threw the pillow and blanket to the floor. His body seemed immobile, face turned from pale to gray and darkened, eyes appeared not to see the family member, lips changed color. His pulse felt increasingly weak. The ambulance arrived and performed resuscitation for 50 minutes before declaring the patient dead.