Medical Record Activities • CHAPTER 10 499
Reading
Practice pronunciation of medical terms by reading the following medical report aloud.
Rotator Cuff Tear, Right Shoulder
PREOPERATIVE DIAGNOSIS:Rotator cuff tear, right shoulder. Degenerative arthritis, right acromioclavicular
joint. Calcific tendinitis at the level of the superior glenoid tuberosity, right shoulder. Early degenerative osteoarthritis
of the right shoulder. History of gouty arthritis.
POSTOPERATIVE DIAGNOSIS:Rotator cuff tear, right shoulder. Degenerative arthritis, right acromioclavicular
joint. Calcific tendinitis at the level of the superior glenoid tuberosity, right shoulder. Early degenerative osteoarthritis
of the right shoulder. History of gouty arthritis.
OPERATION:Open repair of rotator cuff, open incision outer end of clavicle, anterior acromioplasty, glenohumeral
and subacromial arthroscopy with arthroscopic bursectomy.
FINDINGS:A glenohumeral arthroscopy revealed the superior, anterior, inferior, and posterior glenoid labra were
intact. There was some fraying of the anterior glenoid labrum. The long head of the biceps was intact. We were unable
to visualize any intra-articular calcification. We observed the takeoff of the long head of the biceps from the poste-
rior-superior edge of the glenoid labrum and the glenoid tuberosity. There was an osteophyte inferiorly on the humeral
head. There was a deep surface tear of the rotator cuff at the posterior-superior corner of the greater tuberosity of the
humerus at the infraspinatus insertion. There was an extremely dense subacromial bursal scar. There was prominence
of the inferior edge of the AC joint, with inferior AC joint and anterior acromial spurs.
Evaluation
Review the medical report above to answer the following questions. Use a medical dictionary such as Taber’s
Cyclopedic Medical Dictionaryand other resources if needed.
- What type of arthritis did the patient have?
- Did the patient have calcium deposits in the right shoulder?
- What type of instrument did the physician use to visualize the glenoid labra?
- What are labra?
- Did the patient have any outgrowths of bone? If so, where?
- Did they find any deposits of calcium salts within the shoulder joint?