Hip Joint Injection

Hip Joint Injection

Procedure:  Hip Injection

Procedure in Detail:  The patient/family member has been informed of the risks and benefits of the planned procedure.  Informed consent was obtained.

In the fluoroscopy room, the patient was placed in a prone position and the skin over the left/right hip was prepped and draped in a sterile manner.  The hip joint was identified on fluoroscopy.  The skin and deeper tissues were numbed with 0.5% lidocaine.  Under fluoroscopic guidance a 3½ inch, 22 gauge spinal needle was advanced into the cavity of the hip joint.  The joint was injected with a mixture of 4 cc each of 1/8th Marcaine and 40 mg each of methylprednisolone.

The patient tolerated the procedure well.  The patient’s vital signs were monitored during the procedure.

Complications:

None.  Vital signs are stable during and after the procedure.

Full discharge instructions were given to the patient.  Patient was discharged in a stable condition.

Follow up:

I shall follow up in six weeks time to evaluate the progress.

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Liposuction Procedure

Liposuction

Preoperative diagnoses:

1.      Deformity, right breast reconstruction.

2.      Excess soft tissue, anterior abdomen and flank.

3.      Lipodystrophy of the abdomen.

Postoperative diagnoses:

1.      Deformity, right breast reconstruction.

2.      Excess soft tissue, anterior abdomen and flank.

3.      Lipodystrophy of the abdomen.

Procedures Performed:

1.      Revision, right breast reconstruction.

2.      Excision, soft tissue fullness of the lateral abdomen and flank.

3.      Liposuction of the supraumbilical abdomen.

Anesthesia: General.

Indications:  The patient is a 41-year-old white female who previously has undergone latissimus dorsi flap and implant, breast reconstruction.  The patient now had lateralization of the implant with loss of medial fullness for correction.  It was felt that mobilization of the implant medially would provide the patient significant improvement and this was discussed with the patient at length.  The patient also had a small dog ear in the flank area on the right from the latissimus flap harvest, which was to be corrected.  She had also had liposuction of the periumbilical and infraumbilical abdomen with desire to have great improvement superiorly, was felt to be a candidate for such.  The above-noted procedure was discussed with the patient in detail.  The risks, benefits and potential complications were discussed.  The patient was marked in the upright position and then taken to the operating room for the above-noted procedure.

Procedure in Detail:  The patient was taken to the operating room and placed in the supine position.  Following adequate induction of general LMA anesthesia, the chest and abdomen was prepped and draped in the usual sterile fashion.  The supraumbilical abdomen was then injected with a solution of 5% lidocaine with epinephrine, as was the dog ear.  At this time, the superior central scar was then excised, dissection continued through the subcutaneous tissue, the underlying latissimus muscle until the capsule of the implant was reached.  This was then opened.  The implant was removed and placed on the back table in antibiotic solution.  Using Bovie cautery, the medial capsule was released and undermining was then performed with release of the muscle to the level of the proposed medial projection of the breast.  The inframammary fold medially was secured with 2-0 PDS suture to create greater takeoff point at this level which in the upright position and using a sizer produced a good form.  The lateral pocket was diminished by series of 2-0 PDS suture to provide medialization of the implant.  The implant was then placed back into the submuscular pocket with much improved positioning and medial fullness.  With this completed, the implant was again removed, antibiotic irrigation was performed.  A drain was placed and brought out through a separate inferior stab wound incision and hemostasis was confirmed.  The implant was then replaced and the wound was then closed in layers using 2-0 PDS running suture on the muscle and 3-0 Monocryl Dermabond subcuticular sutures.  The 2.5 cm dog ear was then excised into and including the subcutaneous tissue, even contouring was achieved and this was closed with two layers using 3-0 Monocryl suture.  Using a #3 cannula, a superior umbilical incision, liposuction was carried out into the supraumbilical abdomen, removing approximately 40 to 50 mL of fat with improved supraumbilical contours.  This was closed with 6-0 Prolene suture.  The patient was placed in a compressive garment after treating the incision with Dermabond, Steri-Strips and antibiotic ointment around the drain site and umbilicus.  A Kerlix dressing and a surgical bra was placed to the chest area.  A compressive garment was placed.  The patient was then aroused from anesthesia, extubated, and taken to the recovery room in stable condition.  Sponge, needle, lap, instrument counts were all correct.  The patient tolerated the procedure well.  There were no complications.  The estimated blood loss was approximately 25 mL.

Lumbar Spine X-ray, AP and Lateral Views

X-RAY EVALUATION OF THE LUMBAR SPINE, AP AND LATERAL VIEWS

INDICATION FOR STUDY:         Lumbar fusion.  Follow-up.  Prior examination from November 22, 2010.

FINDINGS:               There is continued evidence of postsurgical changes with transfixing plate and screws from L2 through S1.  There are prior laminectomy changes.  The metallic hardware appears in good position and without gross abnormality.  There is no significant new area of acute abnormality.  There is continued evidence of slight chronic changes and osteopenia of the bones.  If there is any further concern, would recommend further evaluation as needed.

X-Ray of the Cervical Spine

X-RAY EVALUATION OF THE CERVICAL SPINE

FINDINGS:  Views of the cervical spine shows loss of the usual cervical lordosis.  The vertebral body heights and disc spaces appear normally maintained and oblique films fail to demonstrate any significant encroachment upon the neuroforamina, though there may be some posterior osteophyte formation seen at C5-C6 and a cervical MRI may be of further diagnostic value in better defining this questioned defect.

Flexion and extension views show no evidence of subluxation.  The retropharyngeal and retrotracheal air space appears to be normal and soft tissues are otherwise normal.

IMPRESSION:

1.          Loss of the usual cervical lordosis consistent with muscle spasm.

2.     Questioned osteophyte encroachment upon the neuroforamina at C5-C6 and a cervical MRI is recommended for further evaluation.

Chest X-Ray, Two Views

Chest X-Ray, Two Views

FINDINGS:  There is evidence of prior surgery with sternal wires.  The cardiac silhouette appears slightly enlarged.  There is pulmonary vascular prominence, which appears chronic in nature and would recommend clinical correlation.  The possibility of mild congestive heart failure cannot be excluded.  There is no evidence of significant pleural effusions, pneumothorax, or infiltrates.  There is osteopenia of the bones and degenerative changes.

IMPRESSION:  Slight pulmonary vascular prominence, which may be chronic in nature versus mild congestive heart failure.  Prior surgery and mild cardiomegaly.  Would recommend further evaluation as needed.  There are slight atherosclerotic changes to the aorta, which are calcified.

Shoulder Joint Injection

Shoulder joint injection

Procedure in Detail:  The patient/family member has been informed of the risks and benefits of the planned procedure.  Informed consent was obtained.

In the fluoroscopy room, the patient was placed in a supine position and the skin over the right shoulder was prepped and draped in a sterile manner.  The joint  was identified on fluoroscopy.  Under fluoroscopic guidance the skin and deeper tissues were numbed  with 0.5% lidocaine.  Under fluoroscopic guidance, a 3½ inch 22 gauge spinal needle was advanced into the cavity of the shoulder joint.  The joint  was injected with a mixture of 4 cc each of 1/8th bupivacaine and 40 mg each of methylprednisolone .

The patient tolerated the procedure well.  The patient’s vital signs were monitored during the procedure.

Heel Pain Injection

Heel Pain Injection

Procedure Technique:  Informed consent was obtained from the patient.  Special mention was made of the possibility of infection and necrosis of the heel pad.  The patient was placed in the supine position.  The painful area in the medial aspect of the heel was identified by palpation.  After proper preparation with antiseptic solution of the skin, a syringe containing 2 mL of 1% lidocaine was attached to 1.5" 27 gauge needle.  The needle was carefully advanced through the carefully identified point at a right angle to the skin, directly towards the central and medial aspect of the calcaneus.  The needle was advanced very slowly until the needle impinged on the bone, and then was withdrawn slowly.  The contents of the syringe were then gently injected.  Subsequently, the needle was left in place and a syringe containing 2 mL of 0.25% Marcaine and 1 mL of Depo-Medrol was attached to the needle and injected after aspiration at this site.  Subsequently the needle was removed.  Pressure was applied at the site of insertion and once it was made sure there was no bleeding taking place, a small bandage was applied.  The patient tolerated the procedure well.

Knee Joint Injection

Knee Joint Injection

Diagnosis: 

Date of Procedure: 

The patient presents today for a right/left knee joint injection today.

Procedure in Detail:  The patient/family member has been informed of the risks and benefits of the planned procedure.  Procedure is right/left knee joint injection.  Informed consent was obtained.

In the fluoroscopy room, the patient was placed in a supine position and the skin over the right/left knee was prepped and draped in a sterile manner.  The knee joint was identified on fluoroscopy.  The skin and deeper tissues were numbed with 0.5% lidocaine.  Under fluoroscopic guidance, a 3.5-inch, 20 gauge spinal needle was advanced into the cavity of the knee joint.  The joint was injected with a mixture of 4 cc each of 1/8th Marcaine and 40 mg each of methylprednisolone.  The patient tolerated the procedure well.  Complications none.

Flap Revision

Flap Revision

Preoperative Diagnoses:

1.      Bilateral breast asymmetry.

2.      Right breast macromastia.

3.      Right abdominal scar deformity.

4.      Left abdominal scar deformity.

5.      Acquired absence of bilateral breast status post previous bilateral DIEP flap reconstruction.

6.      A 2.3 cm lesion right inferior breast.

7.      Lesion measuring 1.0 cm right inferior breast lateral.

Postoperative Diagnoses:

1.      Bilateral breast asymmetry.

2.      Right breast macromastia.

3.      Right abdominal scar deformity.

4.      Left abdominal scar deformity.

5.      Acquired absence of bilateral breast status post previous bilateral DIEP flap reconstruction.

6.      A 2.3 cm lesion right inferior breast.

7.      Lesion measuring 1.0 cm right inferior breast lateral.

Procedures:

1.      Right breast flap revision.

2.      Left breast flap revision.

3.      Right nipple reconstruction.

4.      Right breast reduction mammoplasty.

5.      Right abdominal scar deformity.

6.      Left abdominal scar deformity.

7.      Excision of right breast lateral lesion enclosure.

8.      Excision of right breast medial lesion enclosure.

Anesthesia:  General.

Complications:  None.

Drains:  None.

Specimens:  Right breast skin and lesions x3.

Indications:  This patient is a 45-year-old white female who presents for a revision of previous bilateral breast reconstruction.  The patient had asymmetry as well as left breast hypertrophy, and therefore, the above-mentioned procedures were indicated.  The patient was informed about the possible risks and complications of the above-mentioned procedures and gave an informed consent.

Procedure:  The patient was brought to the operating room and placed supine on the operative table.  After adequate endotracheal anesthesia was established and IV prophylactic antibiotics were given, the abdomen and chest were prepped and draped in a standard surgical fashion.

First, attention was turned to the left breast where the liposuction was performed laterally to allow for better contour and minimize the outer quadrant.  The incision was made for this and was then closed with 3-0 Prolene interrupted suture.

Then, attention was turned to the right breast where the liposuction was also performed to reduce the medial superior and lateral quadrants.  Once this was performed, the vertical reduction mammoplasty was outlined.  Prior to that, the nipple reconstruction was performed with a keyhole pattern flap.  The flap was elevated with 16-blade and hemostasis was then obtained with the Bovie.  The flap was then sutured onto itself and secured with 3-0 Prolene interrupted sutures.  Then the lateral and medial limbs were undermined to close the defect and this was performed with 6-0 Monocryl interrupted sutures.  Subsequently, the reduction mastectomy skin was then excised sharply and passed up the table marked and sent to Pathology.

Hemostasis was then obtained with the Bovie and then undermining was performed in the medial, superior, and lateral skin to allow for closure of the reduction incisions.  Once this was done, a 6-0 Monocryl interrupted sutures were used to close the inferior limb.  Subsequently 4-0 PDS continuous suture was then placed in the periareolar area to close the defect, with a diameter that equaled the new nipple areolar complex.  Once this was done, the remaining incision was then closed with 6-0 Monocryl followed by 2-0 Monocryl subcuticular sutures.  Subsequently, the two lesions were excised, the larger one which was medial and the lateral one that was smaller that were excised sharply, passed up the table and sent to Pathology.  They were closed in 2 layers using 6-0 Monocryl followed by 2-0 Monocryl subcuticular suture.

Attention was then turned to the abdominal scars where liposuction and tumescent solution of diluted epinephrine were used to minimize the amount of excision that was required.  Subsequently, the extra skin was excised sharply in an elliptical fashion on the right side measuring approximately 7 x 2 cm, this was the superior and inferior skin, was when undermined and closure was performed after hemostasis was obtained with 6-0 Monocryl followed by 2-0 Monocryl subcuticular suture.

Attention was then turned to the contralateral left side where there was a larger defect.  There was a larger excision required measuring approximately 14 x 2 cm.  The superior and inferior edges of skin were undermined and closed primarily using 6-0 Monocryl followed by 2-0 Monocryl subcuticular sutures.  Steri-Strips were placed on all incisions followed by surgical bra.

The patient tolerated the procedure well and was extubated without complications and transferred to the recovery room in stable condition.  All instruments, needle counts, and sponges were correct at the end of the case.