Orthopedic surgery encompasses the entire process of caring for
the surgical patient, from diagnostic evaluation to the preoperative
evaluation and through the postoperative and rehabilitative period.
Although the surgical procedure itself is the key step toward helping
the patient, the preliminary and follow-up care can determine whether
the surgery is successful.
Although it may seem obvious, the history and physical exam are
still important in the evaluation of the patient. Every office visit
is a history and physical exam, whether a new or a return visit. The
completeness of the history and physical has assumed new importance
in view of the complexities required for compliance with federal
regulations. Regulations require that a chief complaint be specified,
and this must be clearly defined because it determines the direction
for the rest of the history and physical. The history must address
the key features of the problem, both to elucidate the medical problem
and to cover the subsidiary requirements for billing purposes. The social
history and past medical history are similarly important because
they change billing codes without necessarily affecting outcome
or success of care. The physical again must cover the essentials
necessary for diagnosis, and frequently the confirmation of the
diagnosis is based on physical exam, but such considerations as
skin condition and blood supply must be documented, despite the
fact that this process is also part of the surgical evaluation.
The next step is imaging and laboratory exams. The most important
point here is to use the most cost-effective examination possible
while keeping patient safety, satisfaction, and convenience in mind.
Roentgenography is still the most cost-effective and most important
initial diagnostic test in the orthopedist’s armamentarium.
Almost every patient should have a radiograph prior to going to
a more sophisticated imaging study. Certain situations are obvious;
for example, a 68-year-old man with knee pain should have standing,
flexed-knee posteroanterior (PA), lateral, and merchant plain film
views taken. If those views show normal joint spaces, consideration
of intraarticular pathology, such as a degenerative meniscus tear,
can be worked up with magnetic resonance imaging (MRI). The normal
views usually ordered are as follows:
1. Neck pain—No
history of trauma, more than 4 weeks’ duration.
2. Thoracic spine pain and tenderness—
Younger than 40 years, no reason to suspect malignancy:
AP and lateral (if history of trauma, or possibility of osteoporosis
on first visit, otherwise at 4 weeks).
3. Lumbar (L)-sacral (S)-spine—
Younger than 40 years, no reason to suspect malignancy
after 4 weeks duration of the pain. With significant trauma, at
first visit, or possible malignancy (ie, weight loss, malaise, fatigue): ...
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