Orthopaedic Surgeon-Vorlage
Ortho On Call Review
Eine professionelle Orthopaedic Surgeon-Vorlage für medizinisches Fachpersonal.
Über diese Vorlage
Streamline your orthopaedic on-call documentation with our 'Ortho On Call Review' template. This essential tool for orthopaedic surgeons and their teams helps capture critical patient information during urgent consultations. From detailed histories of presenting complaints and physical examination findings to X-ray interpretations and comprehensive management plans, this template ensures no detail is missed. Ideal for documenting acute injuries like fractures, it provides a structured format for consultants and registrars. When used with Heidi, our AI medical scribe, this template will intelligently populate sections based on your clinical discussions, ensuring accurate and efficient record-keeping for every orthopaedic emergency.
Vorlagenvorschau
Consultant on call: Dr. Eleanor Vance
Consultant of the week: Dr. Thomas Kelly
Alice Smith 45 Female
Date: 01 November 2024 Hospital Number: AS789012
Issues/Diagnosis: Right Distal Radius Fracture, Colles' type
Date of injury: 30 October 2024
PMH/PSH: Hypertension (controlled with medication), no previous surgeries.
DH: Lisinopril 10mg OD. NKDA (No Known Drug Allergies).
SH: Lives with husband, non-smoker, occasional social alcohol, works as an administrative assistant.
HPC:
* Patient presented to A&E after a fall onto an outstretched right hand yesterday evening.
* Experienced immediate pain and swelling in the right wrist.
* Unable to move wrist since injury.
* No neurovascular deficits reported by patient.
* Denies loss of consciousness or head injury.
On Examination:
Right wrist:
* Obvious deformity (dinner fork deformity) noted.
* Significant swelling and tenderness over the distal radius.
* Reduced range of motion due to pain.
* Intact sensation to light touch in median, ulnar, and radial nerve distributions.
* Capillary refill time less than 2 seconds in all digits.
* Radial pulse palpable and strong.
XR: AP and lateral views of the right wrist show a complete transverse fracture of the distal right radius with dorsal displacement and angulation, consistent with a Colles' fracture. No evidence of carpal bone fracture or dislocation. Ulnar styloid intact.
Plan:
1. Discuss with patient about closed reduction under local anaesthetic in ED or theatre.
2. Proceed with closed reduction and casting. If reduction is unstable, consider k-wire fixation.
3. Arrange for post-reduction X-rays to confirm satisfactory alignment.
4. Refer to fracture clinic for follow-up in one week with new X-rays.
5. Provide patient with cast care instructions and pain management advice (e.g., paracetamol and ibuprofen).
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