T10vcfmrireportpayne.odt

Radiology Exam Report
Patient Name: DOWNING, EDWARD KENT
MRN: 223175
DOB/Age/Sex: 6/15/1935 75 Years Male
FIN: 1022200107
Location: Outpatient//
Patient Type: Outpatient One Time (ROP)
Exam: VR Office Visit - New Patient
Accession No: VR-10-0004907
Exam Status: Completed
Exam Date/Time: 8/10/2010 14:51
Transcriptionist: Payne MD, Cynthia
Ordering Physician: Mikles MD, Mark
Report Status: Final
Transcribed Date/Time: 8/10/2010 16:49
Resident:
Radiologist: Payne MD, Cynthia
Reason for Exam: back pain
RADREPORT
OFFICE VISIT FOR KYPHOPLASTY CONSULTATIONREFERRING PHYSICIAN: Dr. Mark MiklesPRIMARY CARE PHYSICIAN: Dr. Schroeder HISTORY OF PRESENT ILLNESS: 75 year old extremely active for age gentlemanreferred by for evaluation of candidacy for kyphoplasty for T10 compression fracture. Thepain began while jumping rope on June 1. His history is well delineated in WindyChristy's records from the office. A will not repeated here there had been scanned intoPACs system. The pain was initially 3/10 and visual analogue scale now more constantache every day at 5/10. He did not perform his activities of daily living which are actuallyquite extraordinary for man this age. He clearly is highly motivated to return to his levelof exercise. He is taking OxyContin but is not controlling the pain.
PAST MEDICAL HISTORY: Osteopenia of the lumbar spine. On Fosamax. Risk factoris probably ethanol. No smoking history.
IMAGING STUDIES: MRI 8/3/2010 performed at Rex Hospital.
ALLERGIES: NoneMEDICATIONS: {<Listed on the intake sheet>]. {<No anticoagulants>].
MEDICAL DECISION MAKING: Approximately 20 minutes time was spent face to faceand greater than 50% of this time was spent on counseling and coordination of care. Hiswife was present.
Recent related spinal imaging was reviewed as well, including. This included a review ofpertinent history and records; review of all available imaging studies; performing a brief,focused physical examination; and discussing the risks (1% or less) and benefits ofkyphoplasty. The procedure of Kyphoplasty was discussed in detail using a model of avertebral body to demonstrate the procedure. Risks, benefits and alternatives werereviewed, including the option of not intervening and allowing time and conservativetherapy to eventually permit healing. This included a discussion of the two recentlypublished reports on vertebroplasty which showed similar positive outcomes in painreduction with or without cement injection while under conscious sedation with local anesthetic injected on the bones. It was explained these studies only addressedvertebroplasty and not Kyphoplasty. However, the differences between the techniquesare not great and the option was offered to withhold treatment pending furtheranalysis of the recent studies. A prospective controlled trial with a larger number ofpatients was published last year in the Lancet comparing Kyphoplasty to conservativemedical therapy. This study showed a benefit for kyphoplasty. A larger trial ofvertebroplasty compared to conventional medical therapy was published yesterdayshowing clear benefit for vertebroplasty.
All questions were answered. No guarantees as to success or not were made. At thispoint the patient indicated a desire to proceed. This has been scheduled for thiscoming Friday with my partner Dr. Harris pending authorization from his third partycarrier.
Thank you for referring this patient. Sincerely,Cynthia Payne, MDRaleigh RadiologyRex Healthcare Interventional Radiology ServiceSigned (Electronic Signature): 08/10/2010 4:43 pm Signed by: Payne MD, Cynthia Transcribed by: CP

Source: http://ohmelovelo.dnsalias.org/Happenings/2010/VCF/T10VCFMRIreportPayne.pdf