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General Clerking in Orthopaedics
Posted by gerardloh
3 Votes
Ortho General Clerking
a/r/s: age-race-sex
K/c/o : Disease – Duration – medication – follow up
eg: 1) HPT, controlled?, duration, meds, follow up
2) DM, controlled? Duration, meds, follow up…
Refered from?
c/o: pain….etc
Duration : 1 hour
HOPI: short story about problem
eg: Alleged MVA (MB vs car) at Pandan Indah roundabout, at 7pm. Pt was pilon
rider….etc
Fell on right side and sustained immediate pain in right elbow.
Past Medical Hx:
Medications:
Surg Hx:
Social Hx: smoker, alcoholic, occupation, living environment
Systemic review
General : Alert, conscious, Vitals….
CVS: DRNM
Chest: Lungs Clear
Abdomen: soft, non-tender
Musculoskeletal
Inspection:
Swelling, pain, redness..etc
Power 5/5
ROM
Motor and neuro sensations intact
Pulses: DPA/PTA (LL) or Radial/Ulnar (UL)
CRT <2sec
*ABSI (LL): Left and Right foot (in ward)
Radiology: xray of___ : no OM changes, no gas shadows
Impression (dx): cellulitis of right leg
Plan:
______________________________________________________________________________________
____
Orthopedic Progress notes
(A)
<AM/PM/Night/ Post Op / clinic review>
a/r/s:
k/c/o:
Problem: Fracture of femur…
________________
(Post op)
Pre Op Dx
POD_ (day/hours):
PODX:
Findings:
_________________
(B)
Progress:
comfortable in bed
pain tolerable
NIL issues
Oral intake well
afebrile
o/e:
Alert, conscious,
non tachypneic
hydration fair
WI: clean, no pus or discharge, no slough, no active bleeding
Vitals: BP, T, PR, SpO2
Plan:
____________________________________________________________________________________
History of presenting illness
1) Trauma
Came unaided? Crutches/Wheel chair?
Alleged____ (MVA, sports injury, fall etc) time____,
Mechanism of injury ( hand outstretched/ flexed, part contacting surface..etc)
Sustained immediate pain
With bleeding? Open wound? LOC? Swelling? Nausea & Vomiting?
Spinal – PU or BO normal?
2) DFU
DM duration? control? Medications, follow up clinic
signs of DM complications – retinopathy, nephropaty, neuropathy
Ulcer size, slough, pus, bleeding, signs of ifxn
Neuro sensation and motor
Family support
Ix: Xray- OM changes?
3) Abscess/cellulitis
Size (in cm) Swelling? Erythema? Discharge? Pain? Warm? fluctuant? Firm? Mobile?
Fever? Discolouration?
Trauma or Insect Bite
______________________________________________________________________________
Plan
1) DM – DFU
– Duration- F/up clinic- Insulin/OHA
– ABSI in ward
– random glucose, FBS, DXT stix –
– DXT monitoring BD,TDS,QID
– Xray (DFU-OM changes, gas shadow)
– Antibiotics+bactigrass dressingàWDàAmputationàRayàAKA/BKA
2) UL/LL Fractures
– Xray – conservative/manipulation/surgical intervention
a) closed manual reduction
CMR + POP, back slab, splint
– post CMR POP Xray
– Acceptable = TCA
– Unacceptable = reCMR/surgery
-Traction : Skin 10% BW, Musc 5% BW
Surgery: Interlocking plate, Insertion of Long Nail, Intramedullar nail, dynamic hip
screw, K wiring, tension band wiring, bone grafting, wound debridement, wound
exploration, ray amputation, incision and drainage
3) Spinal fractures
– Xray, CT, MRI
– screening test
– PU/BO (PR tone exam)
– stabilization by soft neck brace/ juwet’s brace / body cast
4) Infected wound, cellulitis, abscess
– swab C & S
– antibiotics – Cloxa + C Pen
– PCM
– dressing NS + Bactigrass
– I & D (abscess), saucerisation (carbuncle)
_____________________________________________________________________________________
___
Physical Examination
Swelling and wound
Sensation and motor
ROM
Pulses
CRT
Upper Limbs
Sensations:
Ulna = Little finger – ½ ring finger
radial = dorsal btwn thumb-index finger, post-medial forearm, Triceps
median = thumb- ½ ring finger
musculocutaneous = regimental badge
Motor components
a) Ulna: abduction fingers, thumb to little finger
b) Radial: wrist extension
c) Median : thumb abduction
Lower Limbs
Sensations
Thighs: Lateral cutaneous (lat), Femoral (ant-knee-med leg), Obturator (med), Post Cut
(post)
Leg: Sciatic (lat-post-dorsal), common peroneal (lat-ant-dorsal) Femoral (med)
Foot: Deep Peroneal (btwn big-2nd toe), Tibial (rest of toes), Sural (lat)
Plantar: Sural (lat), Lateral Plantar (lat), Medial plantar (med), saphenous(med),
calcaneal (heel)
Motor components
a) Iliopsoas = flex thigh at hip against resistance (knee 90degrees)
b) Quadriceps femoris (femoral) = extend leg against resistance (flex-straighten leg)
c) Adductors (obturator) = Adduct limb against resistance
< to be continued…neck and spinal traumas >
all info above are based on my documentation while working in Hospital
Ampang….hopefully this may guide you in your Ortho rotation…more to come soon…
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jothi on December 24, 2011 at 11:31 am
thanks….its was very helpringfull…i realy appreciate you work…pls update
about …LA BLOCKS…. ring block.ankle block,wrist block…
Reply
gerardloh on August 17, 2012 at 11:47 am
thanks for your suggestions, I did a section about blocks…download the
ortho HO guide..u will find it there
Reply
Gheeta on December 17, 2014 at 10:12 am
Thank u so much Dr. gerard. Your guide has been so helpful in my first posting.
God Bless.
Reply
Dr F on September 13, 2015 at 5:54 pm
Thanks dude… really appreciate even im in my senior era….
Reply
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