How to Answer Medical Record Preoperative Questions (Complete Guide)

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This question relates to medical record preoperative and requires a structured academic response.

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Structure your response with introduction, analysis, and conclusion.

Key Explanation

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Original Question

MEDICAL RECORD PREOPERATIVE DIAGNOSIS: REMOVAL OF HARDWARE DUE TO PAIN STATUS POST-OP-KNOWLES PIN (X 3) FIXATION OF RIGHT HIP PROCEDURES: REMOVAL OF KNOWLES PIN X 3; RIGHT HIP. POSTOPERATIVE DIAGNOSIS: REMOVAL OF HARDWARE DUE TO PAIN/ STATUS POST-OP-KNOWLES PIN (X 3) FIXATION OF RIGHT HIP SURGEON: ANESTHESIA: GENERAL. ANESTHESIOLOGIST: PROCEDURE: After adequate induction with general anesthesia and the patient on the fracture table, the right lower extremity was stabilized in neutral rotation. Preliminary views were taken with the image intensifier and the AP and lateral plains demonstrating the presence of three Knowles pins in the right hip. The right hip was scrubbed, prepped with Betadine and draped in the usual manner for lateral approach surgery. The location of the Knowles pins was determined with the C-arm and a 3-inch incision was made through previously healed surgical scar. The incision was brought down through subcutaneous tissue, fascia lata and proximal vastus lateralis. As determined by the image intensifier views, a considerable amount of bone had grown over and covered the heads of the Knowles ends. Thus, after appropriate soft tissue dissection and hemostasis, a curved osteotome and mallet was utilized to unroof and expose the squared heads of the Knowles pins. The Knowles pins screw heads were found to be straight alignment with impingement of the distal two (2) pins upon one another. Bony in growth was removed from the periphery of the pin heads utilizing a small straight osteotome and mallet. The screws were removed in their entirety utilizing a vice grip. After complete hardware removal, the bone site was examined and there was no evidence of bone defect propagation nor fracture. The operative site was repeatedly irrigated with saline solution. The vastus lateralis and fascia lata were repaired with figure-of-eight #1-Vicryl suture. A number of subcutaneous sutures of 2-0 Vicryl were applied. The skin was approximated with multiple metallic staples. Xeroform and dry sterile dressings were applied. The patient was removed from the fracture table. Upon completion of the procedure, the peripheral pulses of both lower extremities were bounding. The procedure was tolerated well, and the patient was sent to the recovery room without incident. Electronically signed by 01/01/20XX

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