PATIENT_ID: 59034db9-be2f-4977-b26b-8c53773cd7bf
ENCOUNTER_ID: af0672c9-e222-46b1-9cca-e12b90d8d37e
FIRST_NAME: Leslie
LAST_NAME: Gardner
DOB: 2004-09-07
SEX: F
ADDRESS: 529 Kristi Ridge Apt. 581
CITY: New Amandaville
STATE: OK
ZIP: 73912
PAYER: Kaiser
MEMBER_ID: KAIS-62C8B9B303
ENCOUNTER_TYPE: SURGICAL
SPECIALTY: Orthopedic Surgery
SETTING: Inpatient
ACUITY: LOW
SEQ: 000001
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Date of Service: 2024-12-21
CHIEF COMPLAINT: Patient reports numbness and tingling in the left toes

HPI: The patient is a 45-year-old female who presents with a chief complaint of numbness and tingling in the left toes. The onset of symptoms was gradual, beginning approximately 6 months ago. The location of the numbness and tingling is primarily in the left toes, but occasionally radiates to the left foot. The duration of symptoms is constant, with the patient experiencing numbness and tingling throughout the day. The character of the numbness and tingling is described as a pins-and-needles sensation. Aggravating factors include prolonged standing or walking, while relieving factors include rest and elevation of the left leg. The timing of symptoms is constant, with no specific pattern or trigger. The severity of symptoms is mild to moderate, with the patient rating the pain as 3/10.

Prior to presentation, the patient tried over-the-counter pain medications, including ibuprofen and acetaminophen, with minimal relief. The patient also underwent a trial of physical therapy, which provided some relief but did not completely resolve symptoms. Labs and imaging workup included a complete blood count, comprehensive metabolic panel, and X-rays of the left foot, all of which were within normal limits. Associated symptoms present include mild swelling in the left foot and occasional shooting pains in the left leg. Associated symptoms absent include fever, chills, and redness.

ROS:
Constitutional: Patient reports fatigue and malaise
HEENT: Patient has a history of seasonal allergies
Cardiovascular: Patient has a history of hypertension
Respiratory: Patient has a history of asthma
GI: Patient reports occasional constipation
GU: Patient reports occasional urinary frequency
MSK: Patient reports mild stiffness in the left knee
Neurological: Patient reports numbness and tingling in the left toes
Psychiatric: Patient has a history of anxiety
Endocrine: Patient has a history of hypothyroidism
Skin: Patient reports occasional dry skin
Hematologic: Patient has a history of anemia

PAST MEDICAL HISTORY: The patient has a history of chronic conditions, including hypertension, asthma, and hypothyroidism. The patient has undergone surgical procedures, including a cesarean section and a tonsillectomy. The patient has been hospitalized in the past for pneumonia and a motor vehicle accident.

MEDICATIONS: The patient is currently taking the following medications: Aspirin 81mg PO daily, Lisinopril 10mg PO daily, Albuterol 2.5mg PO as needed, Levothyroxine 50mcg PO daily, and Acetaminophen 1000mg PO as needed.

ALLERGIES: The patient has no known allergies.

SOCIAL HISTORY: The patient is a non-smoker and does not use illicit substances. The patient consumes alcohol occasionally and has a history of caffeine use.

VITALS: BP 125/66 mmHg, Temp 98.0 F, HR 63 bpm, RR 16 breaths/min, Pain 3/10, SpO2 96% on room air

PHYSICAL EXAM: General: Well-developed, well-nourished female in no acute distress. CV: Regular rate and rhythm, S1/S2 normal, no murmurs/gallops/rubs, no JVD, 2+ pedal pulses. Resp: Clear to auscultation bilaterally, no wheezes/rhonchi/crackles, symmetric expansion. Neuro: Intact sensation to light touch and pinprick in the right lower extremity, decreased sensation to light touch and pinprick in the left lower extremity. MSK: Mild stiffness in the left knee, full range of motion in the left hip and ankle. Skin: No rash or lesions noted.

ASSESSMENT: The patient has a diagnosis of chronic left foot numbness and tingling, likely secondary to a peripheral neuropathy. The patient also has a history of hypertension, asthma, and hypothyroidism, all of which are currently controlled.

PLAN: 
1. Order a CBC, CMP, and lipid panel to evaluate for underlying metabolic disorders.
2. Order an MRI of the left foot to evaluate for any structural abnormalities.
3. Refer the patient to a neurologist for further evaluation and management of the peripheral neuropathy.
4. Continue the patient on current medications, including Aspirin, Lisinopril, Albuterol, Levothyroxine, and Acetaminophen.
5. Follow up with the patient in 7 days to evaluate for any changes in symptoms.

OPERATIVE REPORT: 
Pre-operative diagnosis: Chronic left foot numbness and tingling
Post-operative diagnosis: Same as pre-operative diagnosis
Anesthesia: General anesthesia 
Positioning: The patient was positioned in the supine position with a pillow under the left leg.
Technique: A left foot exploration was performed, with dissection down to the level of the nerve. The nerve was found to be compressed by a small ganglion cyst, which was removed. Instruments used included a #15 scalpel, Metzenbaum scissors, and a nerve stimulator. Implants used included a 4-0 Vicryl suture.
EBL: 50mL
Specimens: The ganglion cyst was sent to pathology for evaluation.
Closure: The wound was closed with 4-0 Vicryl sutures, and a sterile dressing was applied.
Complications: None
Disposition: The patient was transferred to the post-anesthesia care unit (PACU) in stable condition.

PROCEDURES PERFORMED: Left foot exploration with removal of ganglion cyst

DISCHARGE / DME PLAN: The patient will be discharged home with a follow-up appointment in 7 days. The patient will be given a prescription for pain management and will be instructed to elevate the left leg and avoid heavy lifting or bending.

Meds: 
1. Aspirin 81mg PO daily
2. Lisinopril 10mg PO daily
3. Albuterol 2.5mg PO as needed
4. Levothyroxine 50mcg PO daily
5. Acetaminophen 1000mg PO as needed

Follow-up: needed=true, days_after=7