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What are the patient's symptoms?

What are the patient's symptoms?

Case Studies In Health Information Management
Case Studies In Health Information Management
3rd Edition
ISBN:9781337676908
Author:SCHNERING
Publisher:SCHNERING
Chapter2: Information Protection: Access, Archival, Privacy, And Security
Section: Chapter Questions
Problem 2.40.8C
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PREOPERATIVE DIAGNOSIS Myopathy of undetermined etiology. DATE OF OPERATION: POSTOPERATIVE DIAGNOSIS Myopathy of undetermined etiology. PROCEDURE Right quadriceps muscle biopsy. ANESTHESIA Xylocaine 1% local anesthetic with I.V. sedation. SPECIMEN Muscle biopsy x3. COMPLICATIONS None. November 19, 20xx CLINICAL HISTORY The patient is a 68-year-old male who has had progressive lower back and right leg weakness for approximately 6 months. He notes difficulty climbing stairs or getting up from a chair or bed. He moves slowly. There is mild eyelid ptosis noted. OPERATIVE TECHNIQUE After the induction of I.V. sedation, the right thigh skin was prepped with Betadine and draped In the usual fashion. After infiltration with local anesthesia, a longitudinal incision was made over the anterolateral aspect of the thigh. The incision was deepened through subcutaneous tissue to the quadriceps fascia, which was incised. Three muscle specimens were obtained for biopsy as per Armed Forces Institute of Pathology (AFIP) protocol. A thin core of muscle, approximately the thickness of a pencil, going deep into the muscle was submitted for the first biopsy. Then 2 muscle segments were grasped with biopsy clamps and excised. Pressure was held over the muscle for hemostasis. The wound was irrigated with warm saline solution, and the fascia was reapproximated with 2 Interrupted sutures of # 2-0 Vicryl. The subcutaneous tissue was approximated with inter- rupted sutures of #3-0 Vicryl. The skin was approximated with skin staples. A sterile dressing was applied. The patient was transferred to the recovery room in stable condition. Blood loss during the procedure was minimal.
Transcribed Image Text:PREOPERATIVE DIAGNOSIS Myopathy of undetermined etiology. DATE OF OPERATION: POSTOPERATIVE DIAGNOSIS Myopathy of undetermined etiology. PROCEDURE Right quadriceps muscle biopsy. ANESTHESIA Xylocaine 1% local anesthetic with I.V. sedation. SPECIMEN Muscle biopsy x3. COMPLICATIONS None. November 19, 20xx CLINICAL HISTORY The patient is a 68-year-old male who has had progressive lower back and right leg weakness for approximately 6 months. He notes difficulty climbing stairs or getting up from a chair or bed. He moves slowly. There is mild eyelid ptosis noted. OPERATIVE TECHNIQUE After the induction of I.V. sedation, the right thigh skin was prepped with Betadine and draped In the usual fashion. After infiltration with local anesthesia, a longitudinal incision was made over the anterolateral aspect of the thigh. The incision was deepened through subcutaneous tissue to the quadriceps fascia, which was incised. Three muscle specimens were obtained for biopsy as per Armed Forces Institute of Pathology (AFIP) protocol. A thin core of muscle, approximately the thickness of a pencil, going deep into the muscle was submitted for the first biopsy. Then 2 muscle segments were grasped with biopsy clamps and excised. Pressure was held over the muscle for hemostasis. The wound was irrigated with warm saline solution, and the fascia was reapproximated with 2 Interrupted sutures of # 2-0 Vicryl. The subcutaneous tissue was approximated with inter- rupted sutures of #3-0 Vicryl. The skin was approximated with skin staples. A sterile dressing was applied. The patient was transferred to the recovery room in stable condition. Blood loss during the procedure was minimal.
What are the patient's symptoms?
Transcribed Image Text:What are the patient's symptoms?
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