INFUSE BONE GRAFT
Report
- Report Number
- 1030489-2013-00422
- Event Type
- Injury
- Date Received
- February 8, 2013
- Date of Event
- January 16, 2011
- Report Date
- September 22, 2016
- Manufacturer
- MEDTRONIC SOFAMOR DANEK USA, INC
- Product Code
- NEK
- PMA / PMN Number
- P000058
- Adverse Event
- Yes
- Report Source
- Manufacturer report
- Reporter Location
- IL, US
- Reporter Occupation
- ATTORNEY
Narratives
(B)(6). (B)(4). NEITHER THE DEVICE NOR FILMS OF APPLICABLE IMAGING STUDIES WERE RETURNED TO THE MANUFACTURER FOR EVALUATION. THEREFORE, WE ARE UNABLE TO DETERMINE THE DEFINITIVE CAUSE OF THE REPORTED EVENT. PRODUCTS FROM MULTIPLE MANUFACTURERS WERE IMPLANTED DURING THE PROCEDURE. ALTHOUGH IT IS UNKNOWN IF ANY OF THE DEVICES CONTRIBUTED TO THE REPORTED EVENT, WE ARE FILING THIS MDR FOR NOTIFICATION PURPOSES.
(B)(6). (B)(4).
(B)(4).
(B)(4).
(B)(4).
(B)(4) (DEEP VEIN THROMBOSIS). A GOOD FAITH EFFORT WILL BE MADE TO OBTAIN THE APPLICABLE INFORMATION RELEVANT TO THE REPORT. IF INFORMATION IS PROVIDED IN THE FUTURE, A SUPPLEMENTAL REPORT WILL BE ISSUED.
(B)(4).
A GOOD FAITH EFFORT WILL BE MADE TO OBTAIN THE APPLICABLE INFORMATION RELEVANT TO THE REPORT. IF INFORMATION IS PROVIDED IN THE FUTURE, A SUPPLEMENTAL REPORT WILL BE ISSUED.
A GOOD FAITH EFFORT WILL BE MADE TO OBTAIN THE APPLICABLE INFORMATION RELEVANT TO THE REPORT. IF INFORMATION IS PROVIDED IN THE FUTURE, A SUPPLEMENTAL REPORT WILL BE ISSUED.
IT WAS REPORTED THAT THE PATIENT UNDERWENT A POSTERIOR CERVICAL FUSION C2-C6 USING RHBMP-2/ACS. ON POD 6 THE PATIENT WAS DIAGNOSED WITH "A MASSIVE SEROMA" AND REQUIRED AN EMERGENCY CORRECTIVE SURGERY WHERE THE SEROMA WAS EVACUATED. REPORTEDLY, THE PATIENT IS "PARTIALLY PARALYZED WITH PERMANENT DISABILITY AND PAIN."
IT WAS REPORTED THAT ON, (B)(6) 2010 THE PATIENT WAS SENT FOR EMG AND MRI. (B)(6) 2010 THE PATIENT PRESENTED FOR A PHYSICAL EXAM. ON (B)(6) 2010 PER BILLING RECORDS, THE PATIENT UNDERWENT X-RAYS DUE TO SCOLIOSIS. IMPRESSION: 1. ADVANCED SUBAXIAL CERVICAL SPONDYLOSIS. 2. MODERATE TO SEVERE DEGENERATIVE CENቃAL STENOSIS <(>&<)>OM C2 TO T1. 3. CERVIOAI SPONDYLOTIC MYELOPATHY. 4. FOCAL DEGENERATIVE THORACOLUMBAR SCOLIOSIS WITH THE ABOVE OUTLINED STENOTIC PATHOLOGY. (B)(6) 2010 , THE PATIENT PRESENTED FOR AN OFFICE VISIT FOR REVIEW OF HIS MRI WHICH WAS RECENTLY OBTAINED HERE AT (B)(6). THIS MRI WAS PERFORMED IN PREPARATION FOR HIS UPCOMING CERVIOAL SURGERY ON (B)(6). HIS DIAGNOSIS IS CERVICAL SPONDYLOTIC MYELOPATHY, THE CURRENT PLAN IS TO PERFORM C2 TO T1 CERVICAL LAMINECTOMY AND FUSION FOR HIS ADVANCED MULTISEGMENTAL SPINAL STENOSIS AND CERVICAL CORD COMPRESSION RESULTING IN THE ABOVE DIAGNOSIS. (B)(6) 2011, THE PATIENT PRESENTED FOR POST-OPERATIVE FOLLOW-UP AND UNDERWENT MRI. MRI REVEALED A LARGE SEROMA POSTERIOR TO THE CORD WHICH WAS COMPRESSIVE. (B)(6) 2011, THE PATIENT VISITED THE CLINIC FOR FOLLOW UP. PATIENT HAD A C2-6 PSF ON (B)(6) 2011 AND THEN AN EVACUATION POSTERIOR CERVICAL COMPRESSIVE FLUID SEROMA ON (B)(6) 2011. PATIENT ENDED UP WITH A POST OP C5, C6 PALSY (B)(6) 2011, THE PATIENT PRESENTED FOR FOLLOW UP. (B)(6) 2011, THE PATIENT PRESENTED FOR FOLLOW UP. TWO VIEWS OF THE CERVICAL SPINE WERE OBTAINED. (B)(6) 2011, THE PATIENT PRESENTED FOR MR SPINE LS WWO CONTRAST. IMPRESSION : 1) RECURRENT RIQHT PARACENTRAL DISK EXTRUSION AT L5-S1. 2) SEVERE SPINAL STENOSIS AT L1-2 AND L2-3. (B)(6) 2011, THE PATIENT PRESENTED FOR FOLLOW UP . (B)(6) 2011, THE PATIENT UNDERWENT MRI RIGHT BICEP. (B)(6) 2011, THE PATIENT PRESENTED WITH RIGHT SHOULDER PAIN , DYSFUNCTION AND SEVERE RIGHT WRIST PAIN WHICH IS BOTHERING HIM THE MOST. (B)(6) 2011, THE PATIENT RETURNED FOR FOLLOW-UP. (B)(6) 2011, THE PATIENT PRESENTED FOR FOLLOW UP AND MEDICINE REFILL. THE PATIENT UNDERWENT FOLLOWING PROCEDURES: EMG/NCV ㎅UROLOGY ; MRI CERVICAL SPINE ; X RAYS . (B)(6) 2012, THE PATIENT RETURNED FOR FOLLOW-UP. THE PATIENT HAD BEEN EXPERIENCING SEVERE RIGHT UPPER EXEREMITY SPASMS, RIGHT AXILLARY SPASMS AND RIGHT PECTORALIS SPASM ON (B)(6) 2011 PATIENT PRESENTED WITH LEFT SHOULDER PAIN. (B)(6) 2014 THE PATIENT PRESENTED FOR AN OFFICE VISIT. EXAMINATION OF DAMAGE CAUSED BY (B)(6) 2011 NECK OPERATION TO DETERMINE IF ANY REPAIR IS POSSIBLE WAS DONE. RESULT: NOTHING CAN BE DONE DAMAGE IS PERMANENT. (B)(6) 2014 THE PATIENT UNDERWENT AN MRI. (B)(6) 2014 THE PATIENT PRESENTED FOR AN OFFICE VISIT. (B)(6) 2014 THE PATIENT PRESENTED FOR CATARACT TREATMENT. (B)(6) 2014 THE PATIENT PRESENTED FOR ATTEMPTED PAIN MANAGEMENT. (B)(6) 2014 THE PATIENT UNDERWENT AN EYE LID OPERATION. (B)(6) 2015 THE PATIENT PRESENTED WITH THE COMPLAINTS OF RIGHT HIP PAIN AND RIGHT ANKLE. ON (B)(6) 2015 THE PATIENT PRESENTED WITH THE CHIEF COMPLAINT OF SEVERE PAIN IN RIGHT ANKLE. DIAGNOSES: OSTEOARTHRITIS OF FOOT, SCIATICA. ON (B)(6) 2015 THE PATIENT PRESENTED FOR AN OFFICE VISIT.
IT WAS REPORTED THAT ON (B)(6) 2011 THE PATIENT UNDERWENT THE FOLLOWING PROCEDURES: POSTERIOR CERVICAL FUSION C2 THROUGH C6 WITH CORTICOCANCELLOUS ALLOGRAFT, LOCALLY OBTAINED AUTOGRAFT AND RHBMP-2/ACS. BILATERAL POSTERIOR CERVICAL SEGMENTAL INSTRUMENTATION C-2 THROUGH C6 WITH THE SYNAPSE SYSTEM. C-2 THROUGH C7 CERVICAL LAMINECTOMY FOR DECOMPRESSION OF THE SPINAL CORD. ON (B)(6) 2011 THE PATIENT WAS DISCHARGED ON (B)(6) 2011 THE PATIENT COMPLAINED OF LOST OF USE OF HER RIGHT HAND AND SIGNIFICANT PAIN. ON (B)(6) 2011 THE PATIENT WAS READMITTED TO THE HOSPITAL FOR A SECOND/EMERGENCY OPERATION. THE PATIENT PRESENTED WITH THE PRE-OP DIAGNOSES OF POSTERIOR CERVICAL COMPRESSION FLUID COLLECTION, SEROMA WHICH COULD POSSIBLY BE A CEREBROSPINAL FLUID LEAK, AND UPPER EXTREMITY WEAKNESS. THE POST-OP DIAGNOSES WAS DEEP POSTERIOR CERVICAL COMPRESSIVE SEROMA. ON (B)(6) 2010 PER BILLING RECORDS, THE PATIENT UNDERWENT X-RAYS DUE TO SCOLIOSIS. ON (B)(6) 2012 PER BILLING RECORDS, THE PATIENT UNDERWENT X-RAYS. ON (B)(6) 2012 PER BILLING RECORDS, THE PATIENT UNDERWENT MRI OF SPINE AND ELECTROMYOGRAM.
IT WAS REPORTED THAT ON (B)(6) 2011: PATIENT UNDERWENT ULTRASOUND OF RIGHT EXTREMITY VENOUS DUPLEX. IMPRESSION: THROMBOSIS OF THE CEPHALIC VEIN TO ITS CONFLUENCE WITH THE DEEP SYSTEM. ON (B)(6) 2011, (B)(6) 2011, (B)(6) 2011: THE PATIENT HAD THE FOLLOWING DIAGNOSIS: CERVICAL FUSION/DECOMPRESSION. ON (B)(6) 2011: PATIENT WAS DIAGNOSED WITH CERVICAL DECOMPRESSION. ON (B)(6) 2011: THE PATIENT COMPLAINED OF PAIN IN UPPER BACK AND BILATERAL SHOULDERS. ASSESSMENT: GAIT ABNORMALITY. (B)(6) 2011, (B)(6) 2011: THE PATIENT WAS DIAGNOSED FOR C5-C6 PALSIES STATUS POST CERVICAL LAMINECTOMY AND FUSION C3-C6. ON (B)(6) 2012 THE PATIENT PRESENTED FOR A FOLLOW-UP OF NECK PAIN AND ARM PAIN. THE PATIENT WAS DIAGNOSED FOR CERVICAL SPONDYLOSIS WITH MYELOPATHY, AND SPINAL STENOSIS IN CERVICAL REGION. PER BILLING RECORDS, THE PATIENT UNDERWENT X-RAYS. IMPRESSION: THERE IS SMOOTH KYPHOSIS BUT NO SUBLUXATION. MULTILEVEL DISC SPACE NARROWING IS SEEN. ON (B)(6) 2012 PER BILLING RECORDS, THE PATIENT UNDERWENT MRI OF CERVICAL SPINE W/O CONTRAST AND ELECTROMYLOGRAM. IMPRESSION: RESIDUALS OF C2 THROUGH C6 LAMINECTOMIES AND POSTERIOR FUSION. SIMILAR TO SLIGHTLY MORE PRONOUNCED SPINAL CANAL STENOSIS AT (B)(4). ON (B)(6) 2012 THE PATIENT CAME FOR A FOLLOW-UP VISIT WITH PAIN IN BOTH SHOULDERS AND ARMS. THE PATIENT WAS DIAGNOSED FOR CERVICAL SPONDYLOSIS WITH MYELOPATHY. THE MRI OF CERVICAL REGION REVEALS MODERATE CANAL STENOSIS AT THE (B)(4) LEVEL WHICH IS NOT RESULTING IN ANY SIGNIFICANT CORD DECOMPRESSION. ON (B)(6) 2012 THE PATIENT PRESENTED FOR A FOLLOW-UP OF NECK PAIN. THE PATIENT WAS DIAGNOSED FOR CERVICAL SPONDYLOSIS WITH MYELOPATHY, AND SPINAL STENOSIS IN CERVICAL REGION. ON (B)(6) 2012 THE PATIENT PRESENTED FOR A FOLLOW-UP OF NECK PAIN. THE PATIENT WAS DIAGNOSED FOR CERVICAL SPONDYLOSIS WITH MYELOPATHY, S/P CERVICAL SPINAL FUSION, AND SPINAL STENOSIS IN CERVICAL REGION. X-RAYS OF CERVICAL SPINE REVEAL COMPLETE RADIOGRAPHIC FUSION FROM C3-C7 WITH NO CHANGES IN HIS SPINAL IMPLANTS POSITION. NARROWING OF ALL THE INTERVERTEBRAL DISC SPACES SEEN. HYPERTROPHIC SPONDYLOSIS CHANGES AGAIN SEEN. PATIENT COMPLAINED OF RADICULOPATHIC PAIN IN THE LEFT SHOULDER, AXILLA, AND ARM.
IT WAS REPORTED THAT (B)(6) 2002: THE PATIENT PRESENTED WITH COMPLAINTS OF RIGHT HIP AND GROIN PAIN. PAIN WAS LOCATED PREDOMINANTLY TOWARDS THE GROIN AREA AND ALSO TOWARDS THE UPPER THIGH. THE PAIN WAS INTERMITTENT. HE DESCRIBED THE PAIN AT TIMES AS BEING SHARP AND AT TIMES AS BEING ELECTRICAL. HE UNDERWENT X-RAYS OF THE HIP WHICH REVEALED ARTHRITIC CHANGES IN THE RIGHT HIP JOINT; TOWARDS THE END OF THE VERY BOTTOM OF THE X-RAY, WAS THICKENED CORTEX OF THE FEMUR, LIKELY FROM A PREVIOUS FRACTURE. CLINICAL IMPRESSION: RIGHT HIP ARTHRITIS AND TENDINITIS. ON (B)(6) 2002: THE PATIENT HAD ORBITS FOR SCREENING FOR AN MRI SCAN, WHICH DID NOT DEMONSTRATE ANY EVIDENCE OF METALLIC FOREIGN BODIES IN THE AREA. HE ALSO UNDERWENT MRI OF LEFT HIPS DUE TO RIGHT HIP AND THIGH PAIN. IMPRESSION: MODERATE DEGENERATIVE CHANGE OF THE LEFT HIP JOINT WITH A MODERATE EFFUSION. STRAIN OR INFLAMMATORY CHANGE SURROUNDING THE HAMSTRING INSERTIONS ONTO THE ISCHIAL TUBEROSITIEA BILATERALLY. DEGENERATIVE DISC DISEASE OF THE LUMBAR SPINE. PROMINENT PROSTATE. DIVERTICULOSIS OF THE SIGMOID COLON. MRI OF THE RIGHT HIPS WAS ALSO DONE. IMPRESSION: SEVERE DEGENERATIVE CHANGE OF THE RIGHT HIP JOINT WITH A LARGE EFFUSION. RIGHT THIGH/FEMUR MRI WAS DONE DUE TO RIGHT HIP AND THIGH PAIN. IMPRESSION: STRAIN OR INFLAMMATORY CHANGE SURROUNDING THE HAMSTRING TENDONS AT THE INSERTION SITES ONTO THE ISCHIAL TUBEROSITIES. THE REMAINDER OF THE STUDY WAS UNREMARKABLE. THE HIP JOINTS AND PELVIS WERE REPORTED SEPARATELY. ON (B)(6) 2002: THE PATIENT PRESENTED WITH FOLLOW-UP OF RIGHT HIP ARTHRITIS AND TENDINITIS. CLINICAL IMPRESSION: BILATERAL HIP ARTHRITIS AND TENDINITIS, RIGHT SIDE WORSE THAN THE LEFT. ON (B)(6) 2003: THE PATIENT UNDERWENT MRI OF LUMBAR SPINE DUE TO LOW BACK PAIN WITH NUMBNESS RIGHT LEG TO KNEE. IMPRESSION: DISCOGENIC, DEGENERATIVE AND HYPERTROPHIC CHANGES, AS DESCRIBED, FROM THE L2 TO THE L4 LEVEL WITH ACCOMPANIED CENTRAL CANAL AND FORAMINA, NARROWING. THIS WAS SOMEWHAT MORE PROMINENT AT L2-L3 WHERE THE CENTRAL CANAL WAS AT THE LOWEST LIMITS OF NORMAL TO BORDERLINE STENOSIS. . POST-OPERATIVE AND DEGENERATIVE CHANGES, AS DESCRIBED, L4 TO S1. THERE WAS MARGINAL SPURRING ACCOMPANIED BY DEGENERATIVE DISC MATERIAL CONTRIBUTING TO FORAMINAL NARROWING AT THESE LEVELS WITH FORAMINAL STENOSIS, GREATEST ON THE LEFT AT L4-L5. THE OSTEOPHYTE AND DISC COMPLEX WAS MORE PROMINENT TOWARD THE RIGHT AT L5-S1. CONCERN FOR STRANDING IN THE THECAL SAC ON THE RIGHT AT L3-S1, WHICH MAY INDICATE FOCAL ARACHNOIDITIS. HE ALSO UNDERWENT AP AND LATERAL RADIOGRAPHS OF THE ORBITS IN SCREENING FOR MRI SCAN WHICH SHOWED NO EVIDENCE OF ANY METALLIC FOREIGN BODY. ON (B)(6) 2005: THE PATIENT PRESENTED WITH KNEE PAIN. HE STEPPED WRONG OFF A STAIR AT THE HEALTH CLUB AND HAD PAIN IN THE LEFT KNEE. HE ALSO HAD SWELLING. THE PAIN HAD BEEN FAIRLY DIFFUSE, THOUGH PREDOMINANTLY MEDIOLATERAL AND ANTERIORLY. THE PAIN HAD BEEN CONSTANT. HE DESCRIBED IT AS AN ACHING DISCOMFORT. HE HAD SOME CLICKING AND POPPING SENSATIONS. HE UNDERWENT X-RAYS OF THE LEFT KNEE WHICH REVEALED MODERATE DEGENERATIVE CHANGES. CLINICAL IMPRESSION: LEFT KNEE DEGENERATIVE JOINT DISEASE, POSSIBLE MENISCAL TEAR. ON (B)(6) 2005: THE PATIENT UNDERWENT ORBITAL X-RAYS THAT WERE NEGATIVE FOR ANY EVIDENCE OF METALLIC FOREIGN BODIES. HE ALSO UNDERWENT MRI OF LEFT KNEE DUE TO KNEE PAIN. IMPRESSION: TRICOMPARTMENTAL DEGENERATIVE CHANGE. CHANGES SUGGESTIVE OF PREVIOUS PARTIAL MEDIAL MENISCECTOMY WITH A RECURRENT TEAR OF THE ANTERIOR HORN. COMPLETE TEAR OF THE ACL FROM THE FEMORAL INSERTION SITE WITH A MID-GRADE INJURY OF THE MEDIAL COLLATERAL LIGAMENT. THE REMAINDER OF THE STUDY WAS UNREMARKABLE. ON (B)(6) 2005, (B)(6) 2005, (B)(6) 2005, (B)(6) 2005, (B)(6) 2005: THE PATIENT PRESENTED WITH FOLLOW-UP OF LEFT KNEE DEGENERATIVE JOINT DISEASE. EXAMINATION OF HIS KNEE REVEALED FULL RANGE OF MOTION IN THE KNEE, MILD SWELLING WAS NOTED. EXAMINATION OF HIS RIGHT LITTLE FINGER REVEALED TRIGGERING AND TENDERNESS OVER THE FLEXOR TENDON SHEATH. IMPRESSION: LEFT KNEE DEGENERATIVE JOINT DISEASE WITH MENISCUS TEAR. RIGHT LITTLE TRIGGER FINGER. (B)(6) 2005: THE PATIENT PRESENTED WITH THE FOLLOWING DIAGNOSES: HYPERLIPIDEMIA AND LONG TERM USE OF MEDICATIONS. ON (B)(6)2005: THE PATIENT WAS DIAGNOSED WITH BACK PAIN. ON (B)(6) 2005: THE PATIENT UNDERWENT MRI OF CERVICAL SPINE DUE TO NECK PAIN DOWN RIGHT ARM. IMPRESSION: MODERATE TO SEVERE MULTILEVEL CERVICAL SPONDYLOSIS WITH MULTIPLE LEVELS OF CENTRAL CANAL STENOSIS AND NEURAL FORAMINAL NARROWING. ON (B)(6) 2005: THE PATIENT PRESENTED UNDERWENT MRI OF THORACIC SPINE DUE TO BACK PAIN BETWEEN SHOULDER BLADES. IMPRESSION: DOUBLE CURVATURE THORACIC SCOLIOSIS WITH SUPERIMPOSED SPONDYLOSIS. NO DISC HERNIATION OR DESTRUCTIVE LESION.ON (B)(6) 2005: THE PATIENT PRESENTED WITH THE FOLLOWING DIAGNOSIS: COAGULATION DEFECT. ON (B)(6) 2005: THE PATIENT PRESENTED WITH LEFT LEG JOINT PAIN AND JOINT REPLACEMENT OF KNEE. ON (B)(6) 2006: THE PATIENT PRESENTED WITH CHEST PAIN. HE ALSO COMPLAINED OF SPRAIN IN FOOT, HYPERTENSION, ARTHROPATHY, ACID IN RECREATION AREA AND ACID FROM OVEREXTENSION. HE UNDERWENT CT OF CHEST FOR PULMONARY EMBOLISM WITH ANGIOGRAPHIC IMAGE POST PROCESSING. IMPRESSION: THERE WAS A SMALL AMOUNT OF RIGHT MIDDLE LOBE ATELECTASIS; THERE WAS NO EVIDENCE OF PULMONARY EMBOLISM OR OTHER ABNORMALITY. THE PATIENT UNDERWENT X-RAYS OF THE LEFT FOOT DUE TO PAIN AT LEVEL OF ALCIS. IMPRESSION: NO FRACTURE. ON (B)(6) 2008: THE PATIENT PRESENTED WITH RIGHT UPPER QUADRANT PAIN, RIB CONTUSION AND CHEST PAIN. HE UNDERWENT GALLBLADDER SONOGRAPHY DUE TO RIGHT UPPER QUADRANT ABDOMINAL PAIN. IMPRESSION: NO CHOLELITHIASIS OR CHOLECYSTITIS. COMMON BILE DUCT 3 MM; LIVER NORMAL. ON (B)(6) 2008: THE PATIENT PRESENTED WITH FOLLOWING DIAGNOSES: MALIGNANT NEO BLADDER, HEART DISEASE AND PULMONARY COLLAPSE. THE PATIENT UNDERWENT X-RAYS OF THE CHEST DUE TO BLADDER CANCER. IMPRESSION: STABLE RIGHT MIDDLE LOBE ATELECTASIS. ON (B)(6) 2008: THE PATIENT PRESENTED WITH THE FOLLOWING DIAGNOSIS: PROSTATIC DISORDER. ON (B)(6) 2009: THE PATIENT UNDERWENT COLONOSCOPY DUE TO INTERMITTENT RECTAL BLEEDING. IMPRESSION: DIVERTICULOSIS. INTERNAL HEMORRHOIDS. ON (B)(6) 2009: THE PATIENT PRESENTED WITH BILATERAL HAND NUMBNESS. SINCE (B)(6) 2009, THE PATIENT BEGAN HAVING PAIN AND ELECTRIC SHOCKS IN HIS BILATERAL HANDS ESPECIALLY AT NIGHT. IT WAS WORSE ON THE LEFT AND WAS A BURNING PAIN AND WAS INTERMITTENT AND AWAKES HIM FROM SLEEP. ASSESSMENT: BILATERAL CARPAL TUNNEL SYNDROME. ON (B)(6) 2009: THE PATIENT UNDERWENT ELECTROMYOGRAPHY/NERVE CONDUCTION SPEED EVALUATION FOR BILATERAL UPPER EXTREMITY COMPLAINTS. INTERPRETATION:BILATERAL MEDIAN MONONEUROPATHIES AT THE WRIST, SEVERE IN NATURE. A LEFT ULNAR MONONEUROPATHY AT THE ELBOW. ON (B)(6) 2009: THE PATIENT PRESENTED WITH BILATERAL CARPAL TUNNEL SYNDROME. REVIEW OF HIS NERVE CONDUCTION STUDIES SHOWED THAT HE HAD SEVERE CARPAL TUNNEL SYNDROME AS INDICATED BY MARKEDLY ELEVATED MOTOR LATENCIES, AS WELL AS EVIDENCE OF SOME MODERATE CUBITAL TUNNEL SYNDROME AS SHOWN BY DECREASED CONDUCTION VELOCITY. ASSESSMENT: SEVERE BILATERAL CARPAL TUNNEL SYNDROME. ASYMPTOMATIC CUBITAL TUNNEL SYNDROME. ON (B)(6) 2009: THE PATIENT PRESENTED WITH THE FOLLOWING PRE-OPERATIVE DIAGNOSES: RIGHT CARPAL TUNNEL SYNDROME. LEFT CARPAL TUNNEL SYNDROME. HE UNDERWENT THE FOLLOWING PROCEDURES: RIGHT CARPAL TUNNEL SYNDROME. LEFT CARPAL TUNNEL SYNDROME. NO PATIENT COMPLICATIONS WERE REPORTED. ON (B)(6) 2009, (B)(6) 2009: THE PATIENT PRESENTED STATUS POST BILATERAL CARPAL TUNNEL RELEASES. ASSESSMENT: DOING GREAT STATUS POST BILATERAL CARPAL TUNNEL RELEASES. ON (B)(6) 2010: THE PATIENT WAS ADMITTED WITH THE FOLLOWING DIAGNOSIS: CERVICAL POSTERIOR SEROMA. THE FOLLOWING PROCEDURE WAS PERFORMED ON HIM: CERVICAL WOUND EXPLORATION AND EVACUATION OF SEROMA. ON (B)(6) 2010: THE PATIENT UNDERWENT MRI OF CERVICAL SPINE DUE TO NECK PROBLEMS. IMPRESSION: DEGENERATIVE CHANGES WERE NOTED THROUGHOUT THE CERVICAL SPINE; THERE WAS HIGH-GRADE CANAL STENOSIS AT THE C-2/C3 THROUGH C-5/C6, MOST PRONOUNCED AT C-2/C3 WHERE THERE WAS SUSPECT CORD COMPRESSION; THERE WAS MODERATE TO MARKED STENOSIS OF THE CANID AT C6/C7 AND C7/T-1 WITH MODERATE STENOSIS AT T-1/C-2. THERE WAS MULTILEVEL FORAMINAL STENOSIS. ON (B)(6) 2010: THE PATIENT UNDERWENT ELECTRODIAGNOSTIC TEST. IMPRESSION: THIS WAS AN ABNORMAL STUDY. THERE WAS ELECTRODIAGNOSTIC EVIDENCE OF A GENERALIZED SENSORIMOTOR POLYNEUROPATHY WITH AXONAL GREATER THAN DEMYELINATIVE FEATURES. ELECTROMYOGRAPHIC FEATURES OF REINNERVATION WERE PRESENT IN BOTH PROXIMAL AND DISTAL MUSCLES OF THE LOWER LIMBS, AND FIRST DORSAL INTEROSSEOUS IN THE LEFT-HAND. WHETHER THE LOWER LIMB RE-INNERVATION FEATURES PARTICULARLY PROXIMALLY WERE RELATED IN PART TO THE PRIOR LUMBAR PATHOLOGY WITH SURGERY CANNOT BE DISTINGUISHED WITHOUT PRIOR COMPARISON STUDIES, BUT WAS SUGGESTED BY THE NORMAL FINDINGS IN THE FEMORAL DISTRIBUTION. THE SPONTANEOUS ACTIVITY OBSERVED DISTALLY AND IN THE SHORT HEAD OF THE BICEPS FEMORIS MAY BE RELATED TO THE NEUROPATHY, OR COULD ALSO REPRESENT A SUPERIMPOSED POLYRADICULOPATHY AT THE LS/S1 LEVELS, WHICH COULD NOT BE COMPLETELY RULED OUT DUE TO THE INABILITY TO EVALUATE THE PARASPINAL MUSCLES. A FOLLOW-UP STUDY IN SUGGESTION IF THERE WAS PROGRESSION OF MOTOR SYMPTOMS WITHOUT SENSORY COMPLAINTS, IN THE UPPER LIMBS PARTICULARLY. SLOWING OF RIGHT PERONEAL CONDUCTION ACROSS THE RIGHT FIBULAR HEAD MAY BE RELATED TO THE GENERALIZED NEUROPATHY, BUT MAY ALSO REPRESENT A DEMYELINATIVE RIGHT PERONEAL NEUROPATHY AT THAT LEVEL. ON (B)(6) 2010: THE PATIENT PRESENTED WITH DIFFICULTY IN WALKING. HE ALSO HAD COMPLAINTS OF BILATERAL LOSS OF DEXTERITY IN HANDS AND PROBLEMS WITH FINE MOTOR TASKS. IMPRESSION: ADVANCED SUBAXIAL CERVICAL SPONDYLOSIS. MODERATE TO SEVERE DEGENERATIVE CERVICAL STENOSIS FROM C-2 TO T-1. CERVICAL SPONDYLOTIC MYELOPATHY. FOCAL DEGENERATIVE THORACOLUMBAR SCOLIOSIS WITH THE ABOVE OUTLINED STENOTIC PATHOLOGY. ON (B)(6) 2010: THE PATIENT UNDERWENT X-RAYS OF THE CHEST DUE TO PRE-OP EVALUATION. IMPRESSION: ABNORMAL LATERAL VIEW OF THE CHEST WITH A FOCAL SOFT TISSUE DENSITY PROJECTING OVER THE CARDIAC SHADOW. ON (B)(6) 2010: THE PATIENT UNDERWENT CT OF CHEST DUE TO ABNORMAL CHEST X-RAY. IMPRESSION: LINEAR PARENCHYMAL ABNORMALITIES IN THE RIGHT MIDDLE LOBE IN A PATIENT WITH EITHER RIGHT DIAPHRAGMATIC ELEVATION OR EVENTRATION; CURRENT FINDINGS MAY BE THE RESULT OF THE VOLUME LOSS FROM THE DIAPHRAGMATIC EVENTRATION OR A CHRONIC MIDDLE LOBE SYNDROME, ALTHOUGH SPECIFIC ABNORMALITY TO THE BRONCHUS TO THE SEGMENT OF INTEREST WAS NOT DEMONSTRATED; OTHERWISE, CT OF THE CHEST WITH INFUSION; NO EVIDENCE OF A CENTRAL NEOPLASM. ON (B)(6) 2011 THE PATIENT PRESENTED WITH THE FOLLOWING PREOPERATIVE DIAGNOSES: ADVANCED MULTISEGMENTAL CERVICAL STENOSIS. CERVICAL SPONDYLOTIC MYELOPATHY. PER OP NOTES, THE BONE GRAFT THEN BROUGHT ONTO THE SITE AND, DURING THE DECOMPRESSION PORTION OF THE PROCEDURE, A MEDIUM SIZED RHBMP-2/ACS KIT WAS ALSO PREPARED ON THE BACK STERILE OPERATING TABLE. THE ALLOGRAFTS/AUTOGRAFT MIXTURE DIVIDED INTO TWO EQUAL PORTIONS WAS THEN USED. BONE GRAFT WAS PACKED INTO EACH FACET INDIVIDUALLY AT C2 3 DOWN TO C5. THE MORCELLIZED GRAFT WAS PACKED INTO THESE FACET JOINTS WITH A BAYONET FORCEPS AND A MOE IMPACTOR. TWO RHBMP-2/ACS SPONGES WERE THEN LAID ALONG THE LATERAL MASSES FROM C3 DOWN TO C6 LATERAL TO THE SCREW HOLES OVER THE DECORTICATED LATERAL MASSES BILATERALLY USING ALL FOUR SPONGES FROM THE MEDIUM KIT OF RHBMP-2/ACS. THE REMAINING ALLOGRAFTS/AUTOGRAPH MORCELLIZED GRAFT MATERIAL WAS THEN PACKED LATERALLY FROM C TO DOWN TO C6 WITH (B)(6) FORCEPS AND MOE IMPACTOR. NO PATIENT COMPLICATIONS WERE REPORTED. ON (B)(6) 2011 HE UNDERWENT THE FOLLOWING PROCEDURE: INCISION, EXPLORATION, AND EVACUATION OF A DEEP POSTERIOR CERVICAL POSTOPERATIVE COMPRESSIVE SEROMA. HIS POST-OPERATIVE COURSE WAS ENTIRELY UNEVENTFUL, OTHER THAN SOME MILD BILATERAL DELTOID WEAKNESS ATTRIBUTED TO A POSSIBLE C-5 RADICULOPATHY POST AMINECTOMY, A WELL-KNOWN POSTOPERATIVE COMPLICATION. HE ALSO UNDERWENT MRI OF CERVICAL SPINE SIX DAYS POST-OP, NEW ONSET OF RIGHT ARM PARESTHESIAS. ON (B)(6) 2011: THE PATIENT WAS ADMITTED WITH THE FOLLOWING DIAGNOSES: GAIT ABNORMALITY; DECONDITIONING; CERVICAL SPINAL STENOSIS, STATUS POST LAMINECTOMY AND POSTERIOR SPINAL FUSION C2 THROUGH C6; POSTOPERATIVE SEROMA AT C5-6 WITH EVACUATION AND SUBSEQUENT C5-6 PALSY; HYPERTENSION; BLADDER DYSFUNCTION, PRE-MORBID; HYPONATREMIA; RIGHT UPPER EXTREMITY SUPERFICIAL DEEP VENOUS THROMBOSIS; ATTENTION DEFICIT HYPERACTIVITY DISORDER; PRIOR HISTORY OF (B)(6) IN THE RIGHT ARM WOUND; HEPATITIS A. REVIEW OF SYMPTOMS REVEALED BILATERAL ARM WEAKNESS, MORE ON THE RIGHT, RIGHT THUMB NUMBNESS. ON (B)(6) 2011: THE PATIENT UNDERWENT RIGHT UPPER EXTREMITY VENOUS DUPLEX ULTRASOUND DUE TO RIGHT ARM SWELLING. IMPRESSION: THROMBOSIS OF THE CEPHALIC VEIN TO ITS CONFLUENCE WITH THE DEEP SYSTEM. ON (B)(6) 2011: THE PATIENT COMPLAINED OF BILATERAL SHOULDER SPASMS WITH POSTERIOR/EXTENDED POSTURE. ON (B)(6) 2011: THE PATIENT COMPLAINED OF LEFT SHOULDER AND TIGHTNESS AT MID-NECK. ON (B)(6) 2011: THE PATIENT COMPLAINED OF TIGHTNESS AT MID NECK. ON (B)(6) 2011: THE PATIENT COMPLAINED OF PAIN IN UPPER BACK AND BILATERAL SHOULDERS. ON (B)(6) 2011: THE PATIENT HAD THE FOLLOWING DIAGNOSIS: CERVICAL FUSION/DECOMPRESSION. HE ALSO COMPLAINED OF PAIN IN THE POSTERIOR NECK. ON (B)(6) 2011: THE PATIENT HAD THE FOLLOWING DIAGNOSIS: CERVICAL FUSION/DECOMPRESSION. THE PATIENT ALSO COMPLAINED PAIN IN THE LEFT SHOULDER. ON (B)(6) 2011: THE PATIENT HAD THE FOLLOWING DIAGNOSIS: CERVICAL FUSION/DECOMPRESSION. THE PATIENT ALSO HAD PAIN IN THE NECK AND BACK. ON (B)(6) 2011: THE PATIENT UNDERWENT BILATERAL LOWER EXTREMITY VENOUS DUPLEX ULTRASOUND DUE TO RIGHT LOWER EXTREMITY EDEMA. IMPRESSION: NO EVIDENCE FOR DEEP VENOUS THROMBOSIS OF THE COMMON FEMORAL, FEMORAL, OR POPLITEAL VEINS BILATERALLY. THE PATIENT WAS DISCHARGED. ON (B)(6) 2011: THE PATIENT PRESENTED WITH CERVICAL SPINAL STENOSIS AND HYPERTENSION. ON (B)(6) 2011: THE PATIENT PRESENTED WITH THE FOLLOWING DIAGNOSIS: BILATERAL L5-C6 PALSIES STATUS POST CERVICAL LAMINECTOMY AND FUSION C3-C6. ASSESSMENT: DECREASED BILATERAL SHOULDER RANGE OF MOTION; DECREASED BILATERAL SHOULDER STRENGTH; DECREASED BILATERAL GRIP STRENGTH; UNSAFE WITH TRANSFERS FROM SITTING TO STANDING. ON (B)(6) 2011: THE PATIENT PRESENTED FOR A FOLLOW-UP VISIT STATUS POST CERVICAL FUSION/DECOMPRESSION. ON (B)(6) 2011: THE PATIENT PRESENTED WITH NECK PAIN AND INTERMITTENT LEFT SHOULDER PAIN. ON (B)(6) 2011: THE PATIENT PRESENTED WITH LEFT SHOULDER PAIN. ON (B)(6) 2011: THE PATIENT PRESENTED WITH LEFT SHOULDER PAIN. ON (B)(6) 2011: THE PATIENT UNDERWENT X-RAYS OF THE RIGHT ARM DUE TO CELLULITIS. IMPRESSION: NO RADIOPAQUE FOREIGN BODY, FRACTURE OR OTHER BONY ABNORMALITY OF THE RIGHT FOREARM. ON (B)(6) 2013: THE PATIENT PRESENTED WITH RIGHT HIP DISCOMFORT AND RIGHT ANKLE PAIN. PATIENT SLIPPED ON ICE IN DRIVE WAY. X-RAYS OF THE RIGHT HIP WAS REVIEWED WHICH REVEALED EVIDENCE OF WELL-SEATED TOTAL HIP ARTHROPLASTY WITHOUT EVIDENCE OF SIGNIFICANT LYSIS OR LOOSENING. X-RAYS OF THE RIGHT ANKLE SHOWED EVIDENCE OF MODERATELY SEVERE DEGENERATIVE JOINT DISEASE WITH EVIDENCE OF ESSENTIALLY OBLIQUITY OF THE TALUS WITH EVIDENCE OF THE SUPEROLATERAL CORNER ESSENTIALLY WEDGED INTO THE TIBIOTALAR JOINT IN THAT AREA. IMPRESSION: EVIDENCE OF RIGHT TOTAL HIP ARTHROPLASTY WITH EVIDENCE OF PROBABLY MILD BURSITIS AND IT BAND SYNDROME. EVIDENCE OF RIGHT ANKLE DEGENERATIVE JOINT DISEASE. ON (B)(6) 2013: THE PATIENT WAS DIAGNOSED FOR LOW BACK PAIN AND RIGHT LOWER EXTREMITY RADICULOPATHY. HE WAS ALSO DIAGNOSED FOR SEVERE SCOLIOSIS. ON (B)(6) 2013: THE PATIENT WAS DIAGNOSED FOR IDIOPATHIC SCOLIOSIS, LUMBAR DISC REPLACEMENT, ARTHROPATHY, EDEMA AND PELVIS JOINT PAIN. THE PATIENT UNDERWENT X-RAY OF THE LEFT HIP DUE TO PAIN. IMPRESSION: SUBTLE SCLEROTIC LESION OF 1 CM X 2 CM IN THE LOWER LEFT FEMORAL NECK FOR WHICH FURTHER WORKUP BY MRI OR NUCLEAR BONE SCAN WAS SUGGESTED; NO FRACTURE IN THE HIP OR ACETABULUM; NO AVASCULAR NECROSIS; PRESERVED HIP JOINT SPACE. HE ALSO UNDERWENT X-RAYS OF THE RIGHT HIP DUE TO PAIN. IMPRESSION: NO ACUTE FRACTURE AND NO EVIDENCE OF LOOSENING OF THE FEMORAL OR ACETABULAR PROSTHETIC COMPONENTS OF THE RIGHT HIP. HE UNDERWENT MRI OF LUMBAR SPINE DUE TO LOWER BACK PAIN. IMPRESSION: SIGNIFICANT SCOLIOSIS, AND EXTENSIVE MULTILEVEL DEGENERATIVE CHANGES; LAMINECTOMY WAS PRESENT AT L5. HE ALSO UNDERWENT X-RAYS OF THE LUMBAR SPINE DUE TO PAIN AND NUMBNESS DOWN RIGHT LEG. CONCLUSION: S-SHAPED THORACOLUMBAR SCOLIOSIS WITH THE EACH CURVE MEASURING 32 DEGREES; MARKED NARROWING OF ALL DISC SPACE HEIGHTS THROUGHOUT THE LUMBAR SPINE; NO SPONDYLOLISTHESIS. ON (B)(6) 2013, (B)(6) 2014 PATIENT PRESENTED FOR REFILL REQUEST. ABNORMAL STUDY OF UPPER AND LOWER EXTREMITIES. THERE WAS ELECTRO DIAGNOSTIC EVIDENCE OF A SEVERE, CHRONIC RIGHT CS RADICULOPATHY WITH SEVERE ONGOING MOTOR DENERVATION, THE CHRONIC REINNERVATION POTENTIALS SHOW THERE HAS BEEN EVIDENCE OF AXONAL REGENERATION. THE ABNORMAL BILATERAL MEDIAN NERVE RESPONSES MAY BE PERSISTENT EVEN AFTER CARPAL TUNNEL RELEASE. MODERATE IN SEVERITY, BILATERAL L4/5 AND L5/S1 RADICULOPATHY WITH ONGOING MOTOR DENERVATION, INTERVAL WORSENING WHEN COMPARED TO REPORT (B)(4), THERE WAS ELECTRO DIAGNOSTIC EVIDENCE OF A SUPERIMPOSED LOWER EXTREMITY SENSORIMOTOR POLYNEUROPATHY. MODERATE TO SEVERE. CONSIDER WORKUP FOR LATROGENIC CAUSES. NOTE THAT ABSENT RIGHT SURAL NERVE: WAS ALSO RECORDED IN (B)(6) 2010 REPORT. ON (B)(6) 2013 PATIENT UNDERWENT NERVE CONDUCTION AND EMG. ON (B)(6) 2013 PATIENT PRESENTED FOR OFFICE VISIT. ASSESSMENT: RIGHT LEG PAIN WITH SEVERE L4-L5 AND L5-S1 NEUROPATHY WITH ONGOING MOTOR DENERVATION. CERVICALGIA.
IT WAS REPORTED THAT ON: (B)(6) 2011: THE PATIENT UNDERWENT CHEST X-RAY. CONCLUSION: DECREASED LUNG VOLUMES WITH PERSISTENT ELEVATION RIGHT HEMIDIAPHRAGM; RETICULAR BASILAR OPACITIES LIKELY SUBSEGMENTAL ATELECTASIS; NO PNEUMOTHORAX. ON (B)(6) 2011: PATIENT UNDERWENT VARIOUS TYPES OF TESTS. ON (B)(6) 2011: PATIENT UNDERWENT ASSESSMENT OF VARIOUS SYSTEMS. MUSCULOSKELETAL SYSTEM REVEALED: ARTHRITIS, SPINAL STENOSIS, MRI DEMON STRATES POSTERIOR FLUID COLLECTION. ON (B)(6) 2011: PATIENT PRESENTED FOR FOLLOW UP VISIT. PATIENT UNDERWENT VARIOUS TYPES OF ASSESSMENTS. ON (B)(6) 2011: PATIENT UNDERWENT CHEST X-RAY. CONCLUSION: BIBASILAR ATELECTASIS, RIGHT GREATER THAN LEFT; TRACE BILATERAL PLEURAL EFFUSIONS, BEST SEEN ON THE LATERAL VIEW; AORTIC CALCIFIC ATHEROSCLEROSIS. ON (B)(6) 2011: PATIENT PRESENTED FOR FOLLOW UP VISIT. ON (B)(6) 2011: PATIENT UNDERWENT VARIOUS TYPES OF TEST. ON (B)(6) 2011: THE PATIENT WAS ADMITTED WITH THE FOLLOWING DIAGNOSES: GAIT ABNORMALITY; DECONDITIONING; CERVICAL SPINAL STENOSIS, STATUS POST LAMINECTOMY AND POSTERIOR SPINAL FUSION C2 THROUGH C6; POSTOPERATIVE SEROMA AT C5-6 WITH EVACUATION AND SUBSEQUENT C5-6 PALSY; HYPERTENSION; BLADDER DYSFUNCTION, PRE-MORBID; HYPONATREMIA; RIGHT UPPER EXTREMITY SUPERFICIAL DEEP VENOUS THROMBOSIS; ATTENTION DEFICIT HYPERACTIVITY DISORDER; PRIOR HISTORY OF (B)(6) IN THE RIGHT ARM WOUND; (B)(6). REVIEW OF SYMPTOMS REVEALED BILATERAL ARM WEAKNESS, MORE ON THE RIGHT, RIGHT THUMB NUMBNESS. PATIENT UNDERWENT MRI OF C-SPINE. ON (B)(6) 2011: THE PATIENT PRESENTED FOR MR SPINE ¿LS WWO CONTRAST¿. IMPRESSION: RECURRENT RIGHT PARACENTRAL DISK EXTRUSION AT L5-S1; SEVERE SPINAL STENOSIS AT L1-2 AND L2-3. THE PATIENT ALSO UNDERWENT MRI OF SPINE THORACIC W/O CONTRAST DUE BACK PAIN AND SCOLIOSIS. IMPRESSION: INCIDENTAL BILATERAL AXILLARY CYSTIC LESIONS PARTLY CHARACTERIZED IN THIS EXAM. REVIEW OF THE OUTSIDE CT SCAN CONFIRMS THAT THESE WERE PRESENT 6 MONTHS AGO. ON (B)(6) 2011: THE PATIENT PRESENTED WITH RIGHT SHOULDER PAIN, DYSFUNCTION AND SEVERE RIGHT WRIST PAIN WHICH ARE BOTHERING HIM THE MOST. THE PATIENT UNDERWENT MR UPPER EXT. JOINT ¿WO¿ CONTRAST RIGHT. IMPRESSION: INCOMPLETELY ASSESSED FULL THICKNESS SUPRASPINATUS AND SUBSCAPULAR IS SUPERIOR BUNDLE TENDON TEARS, WITH A SUSPECTED INTRA-ARTICULAR BICEPS LONG HEAD TENDON TEAR. THE BICEPS MUSCLE BELLY APPEARS EDEMATOUS AND RETRACTED DISTALLY; COMMON FLEXOR AND EXTENSOR ORIGINS TENDON UNDERSURFACE TEARS. ON (B)(6) 2011: THE PATIENT UNDERWENT MRI OF UPPER EXTERNAL JOINT ¿W/O¿ CONTRAST. IMPRESSION: COMPLETE TEAR OF THE SUPRASPINATUS TENDON WITH SEVERE FATTY ATROPHY OF THE MUSCLE; TEAR OF THE SUBSCAPULARIS, INVOLVING IT A 75% OF THE TENDINOUS FIBER, WITH MODERATE TO SEVERE FATTY ATOPHY OF THE MUSCLE; RUPTURE OF THE LONG HEAD OF THE BICEPS TENDON; NEAR CIRCUMFERENTIAL LABRAL TEAR; MODERATE TO SEVERE FATTY ATROPHY OF THE TERES MINOR AND INFRASPINATUS WHICH MAY BE SECONDARY TO DISUSE. PATIENT ALSO UNDERWENT MRI OF CERVICAL SPINE W/O CONTRAST DUE TO NECK FUSION. IMPRESSION: POSTSURGICAL CHANGES FROM C2 THROUGH C6 LAMINECTOMIES WITH C2 THROUGH C6 POSTERIOR SPINAL FUSION; MODERATE CENTRAL SPINAL CANAL STENOSIS AT C7-T1 AND T1-T2, STABLE. THERE IS NO EVIDENCE OF SIGNIFICANT CENTRAL SPINAL CANAL STENOSIS FROM C2-C3 TO C6-C7; MODERATE TO SEVERE NEUROFORAMINAL STENOSIS THROUGHOUT THE CERVICAL SPINE AS ABOVE, STABLE.
IT WAS REPORTED THAT ON: (B)(6) 2013, THE PATIENT PRESENTED WITH LOW BACK PAIN. ON (B)(6) 2013, THE PATIENT PRESENTED WITH LOW BACK PAIN , RIGHT LEG PAIN . ON (B)(6) 2013, THE PATIENT PRESENTED FOR PTOSIS CONSULTATION. IMPRESSION: PTOSIS OF EYELID: BUL. ENTROPION . ON (B)(6) 2013, THE PATIENT PRESENTED FOR FOLLOW UP ON PTOSIS OF EYELID. ON (B)(6) 2014, THE PATIENT UNDERWENT MRI OF CERVICAL SPINE. IMPRESSION: MILD CENTRAL CANAL STENOSIS DUE TO BROAD BASED DISC BULGING AND FACET ARTHROPATHY C7-T1. THERE WAS A MODERATE LEFT NEURAL FORAMINAL STENOSIS C7-T1. LONG SEGMENT CERVICAL FUSION SPANNING C2-C6 WITHOUT EVIDENCE OF LOOSENING OF HARDWARE. LAMINECTOMY CHANGES C3-C6. ON (B)(6) 2014, THE PATIENT PRESENTED WITH DIAGNOSIS OF CERVICALGIA AND DISTURBANCE OF SKIN SENSATION. ON (B)(6) 2014: PATIENT PRESENTED FOR OFFICE VISIT. IMPRESSION: MODERATELY SEVERE SUPERIOR VISUAL FIELD LOSS WITH UNTAPPED VISUAL FIELD TESTING. ON (B)(6) 2014, THE PATIENT UNDERWENT AN EYE LID OPERATION. PATIENT PRESENTED WITH FOLLOWING PRE-OP DIAGNOSIS: BLEPHAROPTOSIS. PATIENT UNDERWENT THE FOLLOWING PROCEDURE: BILATERAL UPPER LID BLEPHAROPLASTY. ON (B)(6) 2014: PATIENT PRESENTED FOR OFFICE VISIT. IMPRESSION: CATARACT. ON (B)(6) 2014, (B)(6) 2015: PATIENT PRESENTED FOR OFFICE VISIT. IMPRESSION: SURGERY FOLLOW UP. CATARACT. ON (B)(6) 2015: PATIENT PRESENTED WITH FOLLOWING PRE-OP DIAGNOSIS: MOVEABLE 3-4 MM LESION ELEVATION WITH PATHOLOGY RIGHT UPPER LID. PATIENT UNDERWENT THE FOLLOWING PROCEDURE: EXCISION OF CYSTIC LESION WITH PATHOLOGY, RIGHT UPPER LID. ON (B)(6) 2015 : REVIEW OF SYSTEMS: CONSTITUTIONAL: WEIGHT GAIN AND EXERCISE INTOLERANCE. MUSCULOSKELETAL: MUSCLE ACHES AND WEAKNESS. HAS ZERO RANGE OF MOTION OF CERVICAL SPINE DUE TO FUSION. AFTER EVACUATION OF HEMATOMA HE DEVELOPED BILATERAL C5 RADICULOPATHY WITH RESIDUAL WEAKNESS. HE IS UNABLE TO ELEVATE HIS RIGHT ARM. AP PELVIS ALONG WITH AP AND FROG LEG LATERAL VIEW S OF THE RIGHT HIP REVEAL A TOTAL HIP ARTHROPLASTY ON THE RIGHT WHICH APPEARS STABLE. THE FEMUR IS CLEARLY IN GROWN. THERE IS PROBABLY FIBROUS INGROWTH OF THE CUP .THIS IS NO EVIDENCE OF SIGNIFICANT POLYETHYLENE WEAR. THERE IS NO EVIDENCE OF GROSS LOOSENING AND NO LYSIS ABOUT THE COMPLAINTS. THE LEFT HIP IS UNREMARKABLE. THERE IS SIGNIFICANT ARTHRITIS OF THE LOWER LUMBAR SPINE. X-RAY ANKLE: AP, LATERAL AND MORTISE VIEWS OF RIGHT ANKLE SHOW SEVERE DEGENERATIVE ARTHRITIS WITH BONE ON BONE CONTACT OF THE LATERAL PORTION OF THE MORTISE. THERE IS SOME EROSION OF THE LATERAL TIBIAL PLAFOND. ON EXAMINATION: PATIENT HAS MODERATE SOFT TISSUE REACTIVITY ABOUT THE RIGHT ANKLE AND SOME CREPITATION LATERALLY. HE HAS SOME PAIN AT THE EXTREMES OF MOTION OF HIS ANKLE. IMPRESSION: SUCCESSFUL RIGHT THA WITHOUT LOOSENING-ACHING PAIN OF UNCERTAIN ETIOLOGY. SEVERE DEGENERATIVE ARTHRITIS OF RIGHT ANKLE. ON (B)(6) 2015: PATIENT PRESENTED WITH FOLLOWING PRE-OP DIAGNOSIS: CATARACT AND CORTICAL CHANGES IN RIGHT EYE. PATIENT UNDERWENT THE FOLLOWING PROCEDURE: LEFT EYE PHACO. ON (B)(6) 2015: PATIENT PRESENTED WITH FOLLOWING PRE-OP DIAGNOSIS: CATARACT AND CORTICAL CHANGES IN LEFT EYE. PATIENT UNDERWENT THE FOLLOWING PROCEDURE: LEFT EYE PHACO 07 DEC 2015 THE PATIENT WAS PRESENTED FOR OFFICE VISIT WITH RIGHT ANKLE PAIN. ASSESSMENTS: RIGHT ANKLE VALGUS ARTHRITIS. THE PATIENT UNDERWENT X RAY OF THE RIGHT ANKLE. IMPRESSION: SHOWED THAT HE HAS VALGUS ARTHRITIS THAT IS SEVERE BONE ON BONE. ON (B)(6) 2016, THE PATIENT WAS PRESENTED FOR OFFICE VISIT WITH RIGHT ANKLE PAIN. THE PATIENT UNDERWENT X RAY WHICH REVEALED BONE ON BONE ARTHRITIS, ESPECIALLY ON THE LATERAL ASPECT OF THE TIBIOTALAR JOINT. ON (B)(6) 2016, THE PATIENT UNDERWENT RIGHT TOTAL KNEE REPLACEMENT. PREOPERATIVE DIAGNOSIS: RIGHT ANKLE ARTHRITIS. ON (B)(6) 2016: PATIENT PRESENTED FOR OFFICE VISIT. IMPRESSION: VITREOUS FLOATERS ON BOTH EYES. ON (B)(6) 2016 AS PER BILLING RECORD THE PATIENT WAS PRESENTED FOR OFFICE VISIT WITH PRIMARY OSTEOARTHRITIS RIGHT ANKLE AND FOOT, CELLULITIS OF RIGHT LOWER LIMB. ON (B)(6) 2016, THE PATIENT WAS PRESENTED FOR OFFICE VISIT WITH RIGHT ANKLE WOUND ISSUE. ASSESSMENT: CELLULITIS WITH WOUND EDGE DEHISCENCE AND NECROSIS. IT IS POSSIBLE THAT HE MIGHT HAVE A DEEP INFECTION BUT I REALLY THINK THIS IS CELLULITIS AT THE PRESENT TIME. ON (B)(6) 2016, THE PATIENT WAS PRESENTED FOR OFFICE VISIT FOR FOLLOW UP STATUS POST RIGHT ANKLE REPLACEMENT WITH DEHISCENCE. ASSESSMENTS: HEALING STATUS POST ANKLE REPLACEMENT WITH WOUND DEHISCENCE AND NECROSIS. ON (B)(6) 2016, THE PATIENT WAS PRESENTED FOR OFFICE VISIT WITH STATUS POST RIGHT ANKLE REPLACEMENT WITH WOUND DEHISCENCE AND COMPLICATIONS. ASSESSMENTS: SLOWLY IMPROVING WOUND DEHISCENCE. HEALING ESSENTIALLY AS EXPECTED. ON (B)(6) 2016, THE PATIENT UNDERWENT X RAY OF THE ANKLE. THE PATIENT WAS PRESENTED FOR OFFICE VISIT WITH RIGHT ANKLE REPLACEMENT. ASSESSMENT: ANKLE PAIN STATUS POST ANKLE REPLACEMENT WITH WOUND DEHISCENCE. ON (B)(6) 2016, THE PATIENT WAS PRESENTED FOR OFFICE VISIT FOR FOLLOW UP ON STATUS POST RIGHT ANKLE REPLACEMENT WITH WOUND DEHISCENCE. ASSESSMENTS: STABLE AND SLOWLY HEALING STATUS POST WOUND NECROSIS AND DEHISCENCE. ON (B)(6) 2016, THE PATIENT WAS PRESENTED FOR OFFICE VISIT WITH FOLLOW UP STATUS POST RIGHT ANKLE REPLACEMENT WITH WOUND DEHISCENCE. ASSESSMENTS: POSSIBLE STRESS FRACTURES VERSUS INFLAMMATION SECONDARY TO WOUND COMPLICATION. IT IS POSSIBLE HE IS JUST HAVING PLANTAR FASCIITIS WITH SWELLING FROM HIS WOUND. ON (B)(6) 2016, THE PATIENT WAS PRESENTED FOR OFFICE VISIT WITH RIGHT ANKLE WOUND STATUS POST RIGHT ANKLE REPLACEMENT. ASSESSMENT: CONTINUED SWELLING AND CONCERN FOR DEEP INFECTION VERSUS LOWER EXTREMITY EDEMA FROM A SYSTEMIC ISSUE.
IT WAS REPORTED THAT ON (B)(6)2014: THE PATIENT UNDERWENT MRI OF LUMBAR SPINE WITHOUT CONTRAST. IMPRESSION: T12-L1 ANNULAR BULGE WITH SOME ECCENTRIC DISC EXTRUSION INTO THE FLOOR OF THE NEURAL FORAMINA ON THE RIGHT. THIS FINDING ALONG WITH ARTHRITIC CHANGES ARE RESULTING IN RIGHT NEURAL FORAMINAL STENOSIS WITH SOME BORDERLINE RIGHT NERVE ROOT IMPINGEMENT. L1-2 PROMINENT DIFFUSE ANNULAR BULGE WITH ECCENTRIC COMPONENTS INCLUDING SOME PROMINENT ECCENTRIC COMPONENTS BILATERALLY AS WELL AS SOME ECCENTRIC DISC EXTRUSION INTO THE FLOOR OF THE NEURAL FORAMEN ON THE LEFT. THESE FINDINGS ALONG WITH FACET ARE RESULTING IN BILATERAL NEURAL FORAMINAL STENOSIS WITH SOME BORDERLINE NERVE ROOT IMPINGEMENT, MOST APPARENT ON THE LEFT. THERE IS ALSO NOTE OF BORDERLINE SPINAL CANAL STENOSIS AT THIS LEVEL WITH THE MIDLINE AP DIMENSION OF THE THECAL SAC MEASURING 9.5 MM. L2-3 DIFFUSE ANNULAR BULGE WITH ECCENTRIC COMPONENTS BILATERALLY THAT INCLUDE SOME MINIMAL EXTRUSION INTO THE FLOOR OF THE NEURAL FORAMEN ON THE LEFT. THESE FINDINGS ALONG WITH FACET DJD ARE RESULTING IN BILATERAL NEURAL FORAMINAL STENOSIS AND CLOSE APPROXIMATION TO THE INFERIOR MARGIN OF THE RESPECTIVE NERVE ROOTS. IN AN UPRIGHT POSITION OR WITH FLEXION/EXTENSION, THESE FINDINGS MAY BE MORE PRONOUNCED WITH SOME POTENTIAL BORDERLINE NERVE ROOT IMPINGEMENT THAT SHOULD BE CORRELATED CLINICALLY. L3-4 DIFFUSE ANNULAR BULGE WITH ECCENTRIC COMPONENTS BILATERALLY ALONG WITH SOME ECCENTRIC DISC EXTRUSION INTO THE FLOOR OF THE NEURAL FORAMEN ON THE LEFT. THIS FINDING ALONG WITH FACET DJD IS RESULTING IN NEURAL FORAMINAL STENOSIS WITH SOME MILD CONTIGUITY WITH THE INFERIOR MARGIN OF THE LEFT NERVE ROOT. IN AN UPRIGHT POSITION OR WITH FLEXION/EXTENSION, THIS FINDING IS PROBABLY MORE PRONOUNCED WITH SOME BORDERLINE NERVE ROOT IMPINGEMENT. L4-5 DIFFUSE ANNULAR BULGE WITH ECCENTRIC COMPONENTS ALONG WITH SOME ECCENTRIC DISC EXTRUSION BILATERALLY THAT IS PARTICULARLY NOTABLE ON THE RIGHT. THESE FINDINGS ALONG WITH PROMINENT FACET DJD ARE RESULTING IN BILATERAL NEURAL FORAMINAL STENOSIS WITH SOME SECONDARY NERVE ROOT IMPINGEMENT THAT IS PARTICULARLY NOTABLE ON THE RIGHT. L5-S1 PROMINENT DIFFUSE ANNULAR BULGE WITH SOME ECCENTRIC DISC EXTRUSION BILATERALLY MOST APPARENT ON THE RIGHT. THESE FINDINGS ALONG WITH PROMINENT ARTHRITIC CHANGES ARE RESULTING IN BILATERAL NEURAL FORAMINAL STENOSIS WITH SOME NERVE ROOT I IMPINGEMENT MOST PRONOUNCED ON THE RIGHT. PROMINENT THORACOLUMBAR ROTATORY SCOLIOSIS WITH PROMINENT DIFFUSE SPONDYLOSIS DEFORMANS AND OSTEOARTHRITIS. ON (B)(6) 2014, (B)(6) 2015: THE PATIENT PRESENTED FOR FOLLOW UP DUE TO BRACHIAL NEURITIS, CERVICAL POST-LAMINECTOMY SYNDROME, PAIN IN RIGHT LEG, CHRONIC PAIN SYNDROME, CHRONIC LOW BACK PAIN. ON (B)(6) 2015: THE PATIENT PRESENTED FOR PRE-OPERATIVE CLEARANCE FOR CATARACT SURGERY. ON (B)(6) 2014, (B)(6) 2015,(B)(6) 2016: THE PATIENT PRESENTED FOR A ROUTINE FOLLOW-UP. ON (B)(6) 2015: THE PATIENT PRESENTED FOR AN OFFICE VISIT WITH CHIEF COMPLAINT OF JOINT PAIN. THE PATIENT UNDERWENT PHYSICAL EXAMINATIONS. THE MUSCULOSKELETAL STUDY REVEALED DECREASED RANGE OF MOTION WITH INCREASED PAIN. THE PATIENT UNDERWENT MRI OF LUMBAR SPINE. IMPRESSION: T12-L1 ANNULAR BULGE WITH COME ECCENTRIC DISC EXTRUSION INTO THE FLOOR OF THE NEURAL FORAMINA ON THE RIGHT. THIS FINDING ALONG WITH ARTHRITIC CHANGES ARE RESULTING IN RIGHT NEURAL FORAMINAL STENOSIS WITH SOME BORDERLINE RIGHT NERVE ROOT IMPINGEMENT. L1-2 PROMINENT DIFFUSE ANNULAR BULGE WITH ECCENTRIC COMPONENTS INCLUDING SOME PROMINENT ECCENTRIC COMPONENTS BILATERALLY AS WELL AS SOME ECCENTRIC DISC EXTRUSION INTO THE FLOOR OF THE NEURAL FORAMEN ON THE LEFT. THESE FINDINGS ARE RESULTING IN BILATERAL NEURAL FORAMINAL STENOSIS WITH SOME BORDERLINE NERVE ROOT IMPINGEMENT, MOST APPARENT ON THE LEFT. L2-3 DIFFUSE ANNULAR BULGE WITH ECCENTRIC COMPONENTS BILATERALLY THAT INCLUDE SOME MINIMAL EXTRUSION INTO THE FLOOR OF THE NEURAL FORAMEN ON THE LEFT. L3-4 DIFFUSE ANNULAR BULGE WITH ECCENTRIC COMPONENTS BILATERALLY ALONG WITH SOME ECCENTRIC DISC EXTRUSION INTO THE FLOOR OF THE NEURAL FORAMEN ON THE LEFT. L4-5 DIFFUSE ANNULAR BULGE WITH ECCENTRIC COMPONENTS ALONG WITH SOME ECCENTRIC DISC EXTRUSION BILATERALLY THAT IS PRACTICALLY NOTABLE ON THE RIGHT. L5-S1 PROMINENT DIFFUSE ANNULAR BULGE WITH SOME ECCENTRIC DISC EXTRUSION BILATERALLY MOST APPARENT ON T HE RIGHT. PROMINENT THORACULOMBAR ROTATORY SCOLIOSIS WITH PROMINENT DIFFUSE SPONDYLOSIS DEFORMS AND OSTEOARTHRITIS. ON (B)(6) 2016: PATIENT GOT DISCHARGED. ON (B)(6) 2016: PATIENT GOT ADMITTED INTO REHABILITATION FOR PHYSICAL THERAPY. ASSESSMENT: ACQUIRED VALGUS DEFORMITY OF JOINT OF LOWER LIMB; ESSENTIAL HYPERTENSION; POSTOP CARE; POSTOP PAIN; SCOLIOSIS OF LUMBAR SPINE. ON (B)(6) 2016: PATIENT PRESENTED FOR WOUND CHECK. ASSESSMENT: ACQUIRED VALGUS DEFORMITY OF JOINT OF LOWER LIMB; POSTOP CARE; POSTOP PAIN. ON (B)(6) 2016: PATIENT WAS SEEN FOR DISCHARGE EVALUATION. ASSESSMENT: ACQUIRED VALGUS DEFORMITY OF JOINT OF LOWER LIMB; ESSENTIAL HYPER TENSION; POSTOP CARE; POSTOP PAIN; SCOLIOSIS OF LUMBAR SPINE.
IT WAS REPORTED THAT ON, (B)(6) 2009: THE PATIENT PRESENTED WITH THE FOLLOWING PRE-OPERATIVE DIAGNOSES: RIGHT CARPAL TUNNEL SYNDROME. LEFT CARPAL TUNNEL SYNDROME. HE UNDERWENT THE FOLLOWING PROCEDURES: BILATERAL CARPAL TUNNEL RELEASE SURGERY. PATIENT PRESENTED FOR STRESS TEST AND FOLLOW UP ON HYPERTENSION. ON (B)(6) 2010: PATIENT UNDERWENT MRI OF CERVICAL SPINE WITHOUT CONTRAST DUE TO CERVICAL SPINAL STENOSIS.
IT WAS REPORTED THAT ON (B)(6) 2010 THE PATIENT UNDERWENT X RAYS OF THE RIGHT FOREARM. FINDINGS: TINY CALCIFICATION POSTERIOR TO THE OLECRANON AT EXPECTED LOCATION OF THE INSERTION OF THE TRICEPS TENDON AND CALCIFICATIONS AT ULNOCARPAL JOINT REGION ARC NOTED.
IT WAS REPORTED THAT ON (B)(6) 2002 PATIENT PRESENTED WITH RIGHT HIP AND THIGH PAIN. MRI INDICATED "MODERATE DEGENERATIVE CHANGE OF THE LEFT HIP JOINT WITH A MODERATE EFFUSION. STRAIN OR INFLAMMATORY CHANGE SURROUNDING THE HAMSTRING INSERTIONS ONTO THE ISCHIAL TUBEROSITIES BILATERALLY. DEGENERATIVE DISC DISEASE OF THE LUMBAR SPINE. PROMINENT PROSTATE. DIVERTICULOSIS OF THE SIGMOID COLON." ON (B)(6) 2003 PATIENT PRESENTED WITH LOW BACK PAIN WITH NUMBNESS RIGHT LEG TO KNEE. MRI INDICATED "DISCOGENIC, DEGENERATIVE AND HYPERTROPHIC CHANGES.. FROM THE L2 TO THE L4 LEVEL WITH ACCOMPANIED CENTRAL CANAL AND FORAMINAL NARROWING. THIS IS SOMEWHAT MORE PROMINENT AT L2-L3 WHERE THE CENTRAL CANAL IS AT THE LOWEST LIMITS OF NORMAL TO BORDERLINE STENOSIS. POST OPERATIVE AND DEGENERATIVE CHANGES, AS DESCRIBED, L4 TO S1. THERE IS MARGINAL SPURRING ACCOMPANIED BY DEGENERATIVE DISC MATERIAL CONTRIBUTING TO FORAMINAI NARROWING AT THESE LEVELS WITH FORAMINAL STENOSIS, GREATEST ON THE LEFT AT L4-L5. THE OSTEOPHYTE AND DISC COMPLEX IS MORE PROMINENT TOWARD THE RIGHT AT L5-S1. CONCERN FOR STRANDING IN THE THECAL SAC ON THE RIGHT AT LS-51, WHICH MAY INDICATE FOCAL ARACHNOIDITIS." (B)(6) 2005 X-RAYS OF THE LEFT KNEE INDICATED "MODERATE DEGENERATIVE CHANGES THROUGHOUT THE THREE COMPARTMENTS. (B)(6)/2005 ORBITAL X-RAYS "WERE NEGATIVE FOR ANY EVIDENCE OF METALLIC FOREIGN BODIES." MRI OF THE LEFT KNEE INDICATED "TRICOMPARTMENTAL DEGENERATIVE CHANGE. CHANGES SUGGESTIVE OF PREVIOUS PARTIAL MEDIAL MENISCECTOMY WITH A RECURRENT TEAR OF THE ANTERIOR HORN. COMPLETE TEAR OF THE ACL FROM THE FEMORAL INSERTION SITE WITH A MID GRADE INJURY OF THE MEDIAL COLLATERAL LIGAMENT. (B)(6) 2005 THE PATIENT PRESENTED WITH NECK PAIN DOWN THE RIGHT ARM. MRI OF THE CERVICAL SPINE INDICATED "MODERATE TO SEVERE MULTILEVEL CERVICAL SPONDYLOSIS WITH MULTIPLE LEVELS OF CENTRAL CANAL STENOSIS AND NEURAL FORAMINAL NARROWING. (B)(6) 2005 PATIENT PRESENTED WITH BACK PAIN BETWEEN THE SHOULDER BLADES. MRI OF THE THORACIC SPINE INDICATED "DOUBLE CURVATURE OF THE THORACIC SPINE, PREDOMINANTLY IN THE LOWER THORACIC REGION. THERE ARE MARGINAL SPURS SCATTERED ABOUT THE THORACIC SPINE WITH MINIMAL COMPRESSION OF THE VENTRAL THECAL SAC AT SEVERAL LEVELS. THERE IS NO DISC HERNIATION. THERE IS NO DESTRUCTIVE LESION OF THE BONES AND BONY SIGNAL IS NORMAL. THE SPINAL CORD IS NORMAL IN SIZE, CONTOUR AND SIGNAL INTENSITY. THE FORAMINA ARE WIDELY PATENT. THE PARASPINAL SOFT TISSUES ARE GROSSLY NORMAL." (B)(6) 2009 PATIENT PRESENTED WITH BILATERAL HAND NUMBNESS. WAS DIAGNOSED WITH CARPAL TUNNEL. (B)(6) 2013 PATIENT PRESENTED WITH COMPLAINTS OF RIGHT HIP DISCOMFORT AND RIGHT ANKLE PAIN. AP AND LATERAL X-RAYS OF THE RIGHT HIP INDICATED "EVIDENCE OF WELL-SEATED TOTAL HIP ARTHROPLASTY WITHOUT EVIDENCE OF SIGNIFICANT LYSIS OR LOOSENING. EVIDENCE OF SOME SLIGHT ECCENTRICITY OF THE HEAD." AP, LATERAL, AND MORTISE VIEWS OF THE RIGHT ANKLE INDICATED "EVIDENCE OF MODERATELY SEVERE DEGENERATIVE JOINT DISEASE WITH EVIDENCE OF ESSENTIALLY OBLIQUITY OF THE TALUS WITH EVIDENCE OF THE SUPEROLATERAL CORNER ESSENTIALLY WEDGED INTO THE TIBIOTALAR JOINT IN THAT AREA."
IT WAS REPORTED THAT ON (B)(6) 2011 THE PATIENT PRESENTED SPINAL STENOSIS AND UNDERWENT A C2-C6 FUSION (PER REHAB AND PT NOTES). ALSO RECORDED IN THOSE NOTES WAS THAT THE PATIENT WAS TREATED FOR (B)(6) DURING THE STAY (RIGHT ARM INFECTION) AND A BLOOD CLOT IN HIS RIGHT BICEP. ON (B)(6) 2011 THE PATIENT PRESENTED A NEW ONSET OF C5 WEAKNESS; INABILITY TO FLEX ELBOW AND SHOULDER; AND RIGHT SHOULDER PARESTHESIA. ON (B)(6) 2011 THE PATIENT PRESENTED RIGHT ARM WEAKNESS AND WAS READMITTED TO HOSPITAL. ON (B)(6) 2011 THE PATIENT PRESENTED W/ POST OP SEROMA C5-6 AND C5/6 PALSY. THE PATIENT UNDERWENT SURGERY TO CLEAR HIS CERVICAL SEROMA (PER REHAB AND PT NOTES). ON (B)(6) 2011 THE PATIENT PRESENTED BILATERAL ARM WEAKNESS, RIGHT GREATER THAN LEFT; RIGHT THUMB NUMBNESS; MUSCLE SPASMS; MINIMAL NECK DISCOMFORT; GAIT ABNORMALITY; TRACE ERYTHEMA AND SWELLING WITH SMALL NODULAR AREA IN THE RIGHT MEDIAL ARM; AND LIMITED COORDINATION IN BOTH HANDS. THE PATIENT WAS ADMITTED INTO AN INPATIENT REHAB UNIT. DURING THE PATIENTS STAY HE CONTINUED TREATMENT WITH LINEZOLID FOR (B)(6); HE PRESENTED SUPERFICIAL CEPHALIS VEIN DVT ((B)(6) 2011) AND HYPONATREMIA ; HE EXPERIENCED ONGOING ISSUES WITH BLADDER DYSFUNCTION; ANXIETY; NECK AND SHOULDER DISCOMFORT; NECK AND BACK SPASMS; GAIT ABNORMALITY; AND BILATERAL UPPER EXTREMITY DYSFUNCTION. DURING THE PATIENTS STAY HE UNDERWENT PAIN MANAGEMENT, DAILY PHYSICAL THERAPY; MULTIPLE LABS; RADIOLOGICAL EXAMS; AND CONTINUED USE OF A CERVICAL COLLAR. ON (B)(6) 2011 THE PATIENT PRESENTED RIGHT FOOT AND ANKLE SWELLING. ON THIS DAY, THE PATIENT WAS DISCHARGED FROM THE REHABILITATION UNIT. THE PATIENT WAS SET UP TO WEAR A CERVICAL COLLAR (23 HR DAY) AND RETAIN 24 HR HOME HEALTH CARE. ON (B)(6) 2011 THE PATIENT PRESENTED C5/6 PALSIES AND PATIENT COMPLAINED OF LEFT SHOULDER PAIN. THE PATIENT REPORTED THAT THE FUNCTION OF HIS RIGHT ARM HAD RETURNED WITH THE EXCEPTION OF HIS BICEPS AND SHOULDER MUSCLE. HE WAS WEARING A NECK COLLAR ALL DAY AND ALL NIGHT. HE REPORTED HE WAS AMBULATING SIGNIFICANTLY BETTER BUT THAT HE WAS UNABLE TO EAT WITH HIS RIGHT ARM AND REQUIRED ASSISTANCE WITH BATHING AND DRESSING. ON (B)(6) 2011 THROUGH (B)(6) 2011 THE PATIENT PARTICIPATED IN PHYSICAL THERAPY AND PRESENTED AT VARIOUS TIMES ONE OR A COMBINATIONS OF: BILATERAL ARM, NECK, AND SHOULDER PAIN; BURNING PAIN; TINGLING; LOWER BACK PAIN SORENESS; AND WEAKNESS IN ARMS AND SHOULDER. ON (B)(6) 2013 THE PATIENT PRESENTED BURNING, TIGHTNESS, MUSCLE SPASM, AND PAIN DOWN MOST OF THE RIGHT LEG TO THE FOOT. ON A (B)(6) 2013 IN A RADIOLOGY REPORT IT IS STATED THAT AP AND LATERAL VIEWS OF THE RIGHT HIP SHOWED EVIDENCE OF WELL SEATED... HIP ARTHROPLASTY WITHOUT EVIDENCE OF SIGNIFICANT LYSIS OR LOOSENING AND EVIDENCE OF SLIGHT ECCENTRICITY OF THE HEAD. IT ALSO STATED THAT AP AND LATERAL VIEWS OF THE RIGHT ANKLE WERE TAKEN WHICH SHOWED EVIDENCE OF MODERATE SEVERE DEGENERATIVE JOINT DISEASE WITH EVIDENCE OF THE SUPEROLATERAL CORNER ESSENTIALLY WEDGED INTO THE TIBIOTALAR JOINT AREA. ON (B)(6) 2013 THE PATIENT PRESENTED LOW BACK PAIN; RIGHT LOWER EXTREMITY PAIN; WEAKNESS IN UPPER EXTREMITIES, RIGHT > THAN LEFT. THE PATIENT STATED THAT HE WAS EXPERIENCING ELECTRICAL SHOCK TYPE OF PAIN WHICH BEGAN AT HIS HAMSTRING AND RADIATED DOWN INTO THE RIGHT HEEL. ON (B)(6) 2013 THE PATIENT PRESENTED BILATERAL HIP PAIN; RIGHT LEG RADICULOPATHY; RIGHT LEG NUMBNESS, TINGLING, AND WEAKNESS. THE PATIENT UNDERWENT MULTIPLE RADIOLOGICAL EXAMS. A 2V HIP XR DEMONSTRATED "SUBTLE SCLEROTIC LESION OF 1 CM X 2 CM IN THE LOWER LEFT FEMORAL NECK... "DIFFERENTIAL DIAGNOSIS INCLUDES A SIGNIFICANT BONE OR CHONDROID LESION AND STRESS REACTION..." "...NO FRACTURE IN THE HIP OF ACETABULUM. NO AVASCULAR NECROSIS. PRESERVED HIP JOINT SPACE." A 2V HIP COMP XR (RIGHT) INDICATED "NO FRACTURE AND NO EVIDENCE OF LOOSING OF THE FEMORAL OR ACETABULAR PROSTHETIC COMPONENTS OF THE RIGHT HIP." AN AP AND LAT LUMBAR SPINE MRI WAS CONDUCTED WHICH DEMONSTRATED "SIGNIFICANT SCOLIOSIS AND EXTENSIVE MULTILEVEL DEGENERATIVE CHANGES. LAMINECTOMY IS PRESENT AT L5." PER THE RADIOLOGIST'S FINDINGS: "THERE IS SIGNIFICANT DEXTROSCOLIOSIS. THERE IS BONE MARROW EDEMA AROUND L12-L1 AND L2-3, LIKELY DEGENERATIVE. THERE IS MOTION ON THE AXIAL T2 ACQUISITIONS..." A AP AND LAT LUMBAR SPINE XR WAS TAKEN WHICH SHOWED "S-SHAPED THORACOLUMBAR SCOLIOSIS WITH EACH CURVE MEASURING 32 DEGREES; MARKED NARROWING OF ALL DISC SPACE HEIGHTS THROUGHOUT THE LUMBAR SPINE; AND NO SPONDYLOLISTHESIS." ON 04/25/2013 THE PATIENT UNDERWENT AN EMG WHICH REPORTED EVIDENCE OF "...SEVERE CHRONIC RIGHT C5 RADICULOPATHY WITH SEVERE ONGOING MOTOR DENERVATION... NORMAL BILATERAL MEDIUM NERVE RESPONSES... MODERATE IN SEVERITY BILATERAL L4/5 AND L5/S1 RADICULOPATHY WITH ONGOING MOTOR DENERVATION; AND... EVIDENCE OF A SUPERIMPOSED LOWER EXTREMITY SENSORIMOTOR POLYNEUROPATHY, MODERATE TO SEVERE." ON (B)(6), PER THE DOCTORS NOTES "...EMG SHOWS EVIDENCE OF UPPER TO LOWER EXTREMITIES MODERATE IN SEVERITY BILATERAL L4-L5, L5-S1 RADICULOPATHY WITH ONGOING MOTOR DENERVATION. IT APPEARS TO HAVE WORSENED COMPARED TO REPORT ON (B)(6) 2010. THERE IS ALSO EVIDENCE OF SUPERIMPOSED LOWER EXTREMITY SENSORY MOTOR POLYNEUROPATHY MODERATE TO SEVERE... AS FAR AS THE MRI IS CONCERNED, WHICH WAS DONE (B)(6) 2013, THAT DOES SHOW EVIDENCE OF MULTIPLE LEVELS OF DISC DEGENERATION, FACET ARTHROSIS, CENTRAL CANAL STENOSIS, AND SIGNIFICANT NARROWING OF THE LATERAL RECESSES AT MULTIPLE AREAS FROM T11 TO L4-L5. HE ALSO HAS SIGNIFICANT SCOLIOSIS WHICH DOES CONTRIBUTE TO A LOT OF HIS PROBLEMS."
Devices
| Seq | Brand | Generic | Product Code | Manufacturer | Model | Lot | UDI-DI |
|---|---|---|---|---|---|---|---|
| 54894 | INFUSE BONE GRAFT | FILLER, RECOMBINANT HUMAN BONE MORPHOGENETIC PROTEIN, COLLAGEN SCAFFOLD WITH MET | NEK | MEDTRONIC SOFAMOR DANEK USA, INC | NA | UNK |
Patients
| Seq | Age | Sex | Outcome | Treatment |
|---|---|---|---|---|
| 1 | 00064 YR | Required Intervention| S |