Progress Note
1 November 2024
Date of Surgery: 06/15/24: right femoral osteotomy
Date of Injury: 06/14/24: right femoral shaft fracture
Subjective:
- Patient, a 7-year-old male, presents with ongoing pain and limited mobility in his right leg following a recent femoral osteotomy. Mother reports difficulty with weight-bearing and discomfort, particularly during physiotherapy sessions.
- The patient sustained a right femoral shaft fracture in June, which was subsequently treated with an open reduction and internal fixation, complicated by malunion necessitating the osteotomy. Pain is described as a dull ache, 4/10 at rest, increasing to 7/10 with movement. Aggravated by weight-bearing and relieved slightly by rest and paracetamol. No previous orthopaedic issues or family history of bone disorders.
- Physiotherapy is progressing slowly. Mother reports patient is reluctant to engage due to pain, which is hindering progress on range of motion and strengthening exercises.
- Since the last visit two weeks ago, symptoms have remained largely consistent. There has been no significant improvement in pain levels or functional ability. Mother expresses concern about the slow recovery and impact on the child's daily activities.
Objective:
- Vitals: BP 100/60 mmHg, HR 85 bpm, Temp 36.8°C, RR 18 breaths/min.
- Physical examination findings, with emphasis on musculoskeletal examination including inspection, palpation, range of motion, strength testing, joint stability, presence of deformity, swelling, or tenderness, etc.:
Right Hip:
| Examination | Right Value | Left Value |
|---|---|---|
| Flexion | 80° (painful) | 120° |
| Extension | 0° (painful) | 10° |
| Abduction | 15° (painful) | 40° |
| Adduction | 10° (painful) | 20° |
| Internal Rotation | 5° (painful) | 45° |
| External Rotation | 10° (painful) | 45° |
Right Knee:
| Examination | Right Value | Left Value |
|---|---|---|
| Flexion | 70° (painful) | 140° |
| Extension | -10° (painful) | 0° |
Inspection reveals mild swelling and erythema around the right mid-femur. Palpation elicits tenderness over the osteotomy site. No obvious deformity noted. Strength testing in the right hip and knee is limited by pain (3/5 against resistance). Left lower extremity examination is unremarkable.
- Appearance of the surgical wound: Surgical wound on the right mid-thigh is well-approximated, dry, and clean, with no signs of erythema or discharge. Staples remain intact.
- Neurovascular examination findings, assessing nerve function and blood supply in the affected area, if relevant: Lower extremity neurovascularly intact: Motor exam intact for femoral, sciatic, SPN, DPN, and tibial nerves. Sensation is intact to light touch in all distributions. The capillary refill is less than two seconds.
Imaging:
- For x-rays obtained in the office today, include the following statement and findings: "I ordered and independently reviewed x-rays in office of the right femur today (final radiologist read is pending at the time of the note). The findings are: The right femoral osteotomy site shows early callus formation with good alignment. No signs of hardware loosening or infection."
- Prior X-rays of the right femur acquired on 06/15/24 at Saint Jude's Children's Hospital revealed a malunited femoral shaft fracture. Dr. Smith interpreted these as requiring corrective osteotomy.
Assessment & Plan:
1. Post-operative right femoral osteotomy for malunion of femoral shaft fracture
- Assessment, including the likely diagnosis and rationale based on subjective and objective findings: 7-year-old male with persistent pain and limited range of motion following a right femoral osteotomy. Clinical presentation, including pain with movement, limited ROM, and tenderness at the osteotomy site, is consistent with normal post-operative recovery, albeit slower than anticipated, possibly exacerbated by pain management and physiotherapy compliance issues.
- Investigations planned: Discussed with mother the possibility of a bone scan if pain persists or worsens despite conservative management, to rule out stress reaction or subtle infection.
- Non-surgical treatment options: Continue current physiotherapy regimen with increased emphasis on pain management strategies prior to sessions. Adjust pain medication to include scheduled ibuprofen in addition to paracetamol for better pain control. Referral to a paediatric pain specialist for further assessment and management strategies.
- Post-operative care plan: Continue non-weight bearing for another 2 weeks, then partial weight bearing as tolerated with crutches for 4 weeks. Strict adherence to physiotherapy exercises at home. Follow-up in 4 weeks with repeat X-rays.
- Relevant referrals: Referral to Paediatric Pain Management Clinic and to Paediatric Physiotherapy for reassessment of therapy plan.
Additional Notes:
- Patient education on the diagnosed condition, surgical procedures, potential complications, and the importance of rehabilitation and adherence to post-operative care: Educated mother and patient on the importance of consistent physiotherapy and adherence to pain medication schedule to improve rehabilitation outcomes. Discussed potential complications such as delayed union, non-union, or infection, and signs to watch for.
- Instructions for pre-operative and post-operative care, including activity restrictions, wound care, signs of complications to watch for: Instructed mother on wound care and to monitor for increased redness, swelling, drainage, or fever. Advised strict non-weight bearing for the next two weeks. Emphasised restricted activities, avoiding running, jumping, and contact sports until cleared by the surgeon.
- Any specific patient or family concerns addressed during the consultation: Mother expressed concerns about the patient's refusal to participate in physiotherapy due to pain. We discussed strategies to make physiotherapy more tolerable, including timing pain medication before sessions and using distraction techniques. The importance of balancing pain relief with functional recovery was stressed.
Progress Note
[date of input] (Insert the full date of the clinical encounter in DD/MM/YYYY or standardised clinical format. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Date of Surgery: [Date of surgery] (If mentioned, include in the format MM/DD/YY: surgery described with correct laterality. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Date of Injury: [Date of injury] (If mentioned, include in the format MM/DD/YY: injury described with correct laterality. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Subjective:
- [Reason(s) for consultation, including specific musculoskeletal concerns or symptoms such as joint pain, stiffness, swelling, injuries, fractures, deformities, etc.] (Document the patient’s reported reason for the consultation or follow-up, specifically highlighting musculoskeletal complaints. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [History of the presenting complaint(s), including onset, duration, severity, aggravating/alleviating factors, associated symptoms such as limitation of movement, previous injuries, trauma, any previous treatments and responses, etc.] (Summarise the full narrative history of the presenting issue(s), covering all key dimensions: timeline, pain characteristics, associated trauma, previous investigations, treatments, and the clinical context. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [If doing physiotherapy, whether things are progressing well or poorly] (Document current physiotherapy involvement, patient-reported progress or lack thereof, and any relevant commentary on goals and functional improvement. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [How the symptoms have evolved since the last visit and generally how the patient is progressing] (Describe any changes, improvement or deterioration in symptoms since the last encounter, including patient’s perception of their overall progress. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Objective:
- [Vitals] (Include relevant vital signs such as blood pressure, heart rate, temperature or respiratory rate if assessed. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Physical examination findings, with emphasis on musculoskeletal examination including inspection, palpation, range of motion, strength testing, joint stability, presence of deformity, swelling, or tenderness, etc.] (Be as specific as possible, and include all information mentioned. Detail all musculoskeletal physical exam findings. Include specific joints or areas assessed, presence of pain, effusion, abnormal alignment, deformity, swelling, or tenderness. Include functional tests if applicable. When doing the physical examination of a joint, if an examination is mentioned followed immediately by two values, those values are for the right and left sides, respectively. When I list multiple examinations that way, please list these in chart form with the left-most column a text field describing the examination of a joint (e.g. "Abduction" or "Flexion" under the heading of "Hip"), and the next column is the right-sided values, the left-most column is the left-sided values. If multiple joints are mentioned this way, separate the joints into their own charts. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Appearance of the surgical wound] (Comment on the state of any post-operative wound, including healing status, erythema, discharge, approximation, or signs of infection. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Neurovascular examination findings, assessing nerve function and blood supply in the affected area, if relevant] (Include findings on distal sensation, pulses, capillary refill, motor function and temperature if assessed. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. If I say “Upper extremity neurovascularly intact,” please transcribe that as “Motor exam is intact for axillary, radial, median, AIN, PIN, and ulnar nerves. Sensation is intact to light touch in all distributions. The capillary refill is less than two seconds.” If I say “Lower extremity neurovascularly intact,” please transcribe that as “Motor exam intact for femoral, sciatic, SPN, DPN, and tibial nerves. Sensation is intact to light touch in all distributions. The capillary refill is less than two seconds.“)
Imaging:
- [Investigations with results, including imaging and laboratory tests, etc.] (List imaging results such as X-rays, MRIs, CTs, or lab tests with relevant findings. Include dates and interpret key abnormalities if mentioned. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [For x-rays obtained in the office today, include the following statement and findings: "I ordered and independently reviewed x-rays in office of the [body part with correct laterality] today (final radiologist read is pending at the time of the note). The findings are: [x-ray findings]"] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [For all imaging studies obtained prior to today's visit, include where they were acquired (capitalize business names if mentioned), when they were acquired, and the clinician's interpretation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Outside radiologist interpretation for prior imaging, if available] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. If noted that no radiology interpretation is available, state that.)
Assessment & Plan:
1. [Orthopaedic Issue or Condition] (State the orthopaedic issue or condition being addressed. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Assessment, including the likely diagnosis and rationale based on subjective and objective findings] (State the working or confirmed diagnosis, supported by clinical reasoning drawn from subjective history and objective findings. Include differential diagnosis if relevant. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Investigations planned, specifying any additional imaging, laboratory tests, or assessments needed for a definitive diagnosis or surgical planning] (Detail any upcoming diagnostic tests or imaging ordered to support diagnosis or guide management. Include rationale if provided. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Surgical treatment planned, detailing the type of surgery, the nature of the surgery, and any techniques mentioned] (Document specific surgical procedures being planned, including whether open or arthroscopic, joint involved, technique, and any device or implant mentioned. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Non-surgical treatment options, including physiotherapy, casting or bracing, medications, lifestyle modifications, etc.] (List all conservative treatments recommended including exercise programs, bracing, analgesia, or referrals to allied health professionals. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Post-operative care plan, covering expected hospital stay, rehabilitation, physiotherapy, pain management, and follow-up appointments] (Describe care plans following surgery, including expected recovery timeline, medication plan, referrals to rehab services and scheduled follow-up. If specific timeframes are mentioned, include the exact timeframe stated. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Relevant referrals, e.g., to rheumatology, physiotherapy, pain management, etc.] (Note any referrals made to other departments or external specialists for collaborative management. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
2. [Additional Orthopaedic Issues or Conditions] (Include each additional issue or condition identified. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Follow the same structure as above for each additional issue or condition identified] (Repeat the full assessment and plan structure listed above for any secondary or tertiary orthopaedic issues addressed in the consultation. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Additional Notes:
- [Patient education on the diagnosed condition, surgical procedures, potential complications, and the importance of rehabilitation and adherence to post-operative care] (Document any counselling or education provided to the patient regarding diagnosis, surgical or non-surgical options, prognosis, and importance of adherence to the management plan. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Instructions for pre-operative and post-operative care, including activity restrictions, wound care, signs of complications to watch for] (Record specific instructions provided to the patient or family regarding care before or after surgery, including signs to monitor and when to seek help. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Any specific patient or family concerns addressed during the consultation] (Summarise any questions raised by the patient or family and the responses provided by the clinician. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- "After a discussion of the risks, benefits and alternatives, the family wishes to proceed with surgery" (Use this statement only if informed consent was explicitly documented as obtained during the consultation. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
