General Practitioner-Vorlage
Hand Therapy - General
Eine professionelle General Practitioner-Vorlage für medizinisches Fachpersonal.
Über diese Vorlage
Need a clear and concise way to document hand therapy sessions? This Hand Therapy - General template is perfect for Occupational Therapists. It helps you efficiently record patient details, injury specifics, treatment plans, and progress. This template ensures all key aspects of hand therapy are covered, from the mechanism of injury to the patient's daily life impact. With Heidi, this template can be quickly populated from your session transcript, saving you time and improving the accuracy of your clinical notes. Get organised and improve your documentation with this essential template.
Vorlagenvorschau
Area/s requiring treatment:
- Right wrist, sustained injury on 20 October 2024.
- No surgery required.
Mechanism:
- Fell from a bicycle, landing on outstretched hand.
Patient background:
- Right hand dominant.
- Works as a software engineer.
- Lives with spouse and two children.
Past Medical History:
- No significant past medical history.
- No relevant social history.
- No relevant family history.
- No exposure history.
- Up to date with immunizations.
- No other relevant subjective information.
Subjective/current symptoms:
- Reports pain in the right wrist, following a fall.
- Pain is described as a sharp ache, located on the dorsal aspect of the wrist, rated 6/10. Pain is worse with movement and better with rest.
- Patient has tried over-the-counter pain medication (ibuprofen) with minimal relief.
- Symptoms have remained consistent since the injury.
- No previous similar episodes.
- Difficulty with typing and lifting objects, impacting work and daily activities.
- No associated symptoms.
Objective:
- Blood pressure: 120/80 mmHg, Heart rate: 78 bpm, Respiration rate: 16 breaths/min, SpO2: 98% on room air.
- Observation: Mild swelling and bruising over the dorsal wrist. Palpation: Tenderness over the scaphoid and distal radius. Range of motion: Limited wrist flexion and extension. Grip strength: Reduced compared to the left hand. Neurovascular: Intact.
Investigations:
- X-ray of right wrist: Revealed a non-displaced fracture of the scaphoid.
Assessment:
- Scaphoid fracture, right wrist.
- Differential diagnosis: Distal radius fracture, wrist sprain.
Treatment:
- Custom wrist orthosis prescribed for immobilization. Wearing regime: Worn full-time for 6 weeks, removed for hygiene and exercise. Exercises prescribed: Gentle range of motion exercises for fingers and elbow. Precautions discussed: Avoid heavy lifting and twisting motions.
- Occupational therapy planned.
Plan:
- Follow-up X-rays in 6 weeks to assess fracture healing.
- Referral to hand surgeon if fracture does not heal.
- Patient education on orthosis use and home exercise program.
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