Clinician Specialty: Paediatric Orthopaedic Surgeon
Chief Complaint:
Right distal radius fracture.
Date of Surgery: 11/15/24: Closed reduction and percutaneous pinning of right distal radius fracture
Date of Injury: 11/01/24: Fall onto outstretched right hand.
History of Present Illness:
Liam O'Connell, a 7-year-old patient, is accompanied by his mother for evaluation of a right distal radius fracture. The mechanism of injury was a fall from a bicycle onto an outstretched right hand while playing in the park. The patient initially sought treatment at St. Elsewhere's Urgent Care where they received a temporary splint. Dr. Sarah Jenkins referred the patient to our office for further evaluation. This is not the patient's first orthopaedic injury. His mother was present and contributed significantly to the historical account.
Objective:
- Vitals: BP 100/60, HR 85, Temp 37.0°C, RR 18.
- 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.
Wrist:
Inspection: Obvious swelling and dorsal angulation of the right wrist. Skin intact.
Palpation: Tenderness to palpation over the distal radius. No crepitus.
Range of Motion:
| Examination | Right (°) | Left (°) |
|-------------|-----------|----------|
| Flexion | 20 (painful)| 70 |
| Extension | 15 (painful)| 60 |
| Ulnar Dev. | 10 (painful)| 30 |
| Radial Dev. | 5 (painful) | 20 |
Strength Testing: Limited secondary to pain. Grossly intact in unaffected joints.
Joint Stability: Not assessed due to acute injury.
- Neurovascular examination findings, assessing nerve function and blood supply in the affected area, if relevant: 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.
Imaging:
- Investigations with results, including imaging and laboratory tests, etc.: X-rays of the right wrist taken today demonstrate a displaced Salter-Harris type II fracture of the distal radius with dorsal angulation and metaphyseal comminution.
- In-office x-rays: I ordered and independently reviewed x-rays in office of the RIGHT WRIST today (final radiologist read is pending at the time of the note). The findings are: Displaced Salter-Harris type II fracture of the distal radius with dorsal angulation.
- Prior imaging studies: None.
- Outside radiologist interpretation: Radiologist at St. Elsewhere's Urgent Care reported a 'likely distal radius fracture, recommend orthopaedic follow-up'.
Assessment & Plan:
1. Right Distal Radius Fracture (Salter-Harris Type II)
- Assessment, including the likely diagnosis and rationale based on subjective and objective findings: The patient presents with a displaced Salter-Harris Type II fracture of the right distal radius. This diagnosis is supported by the mechanism of injury (fall onto outstretched hand), acute pain and deformity, and confirmed by in-office X-rays. The displacement warrants surgical intervention to achieve appropriate alignment and prevent future growth disturbances.
- Investigations planned, specifying any additional imaging, laboratory tests, or assessments needed for a definitive diagnosis or surgical planning: Pre-operative blood work (FBC, U&E) and anaesthetic review.
- Surgical treatment planned, detailing the type of surgery, the nature of the surgery, and any techniques mentioned: Closed reduction and percutaneous pinning of the right distal radius under general anaesthesia. The fracture will be reduced manually, and K-wires will be inserted across the fracture site to maintain stability.
- Non-surgical treatment options, including physiotherapy, casting or bracing, medications, lifestyle modifications, etc.: Non-surgical management with cast immobilisation was discussed but deemed unsuitable due to the significant displacement and potential for malunion or growth arrest. Pain management will include paracetamol and ibuprofen, to be commenced immediately post-operatively.
- Post-operative care plan, covering expected hospital stay, rehabilitation, physiotherapy, pain management, and follow-up appointments: Patient to remain overnight for observation. Cast immobilisation for 4-6 weeks post-surgery. Physiotherapy to commence after cast removal, focusing on range of motion and strengthening. Follow-up appointments scheduled for 1-week post-op for wound check and 6-weeks post-op for K-wire removal and X-ray review. Full recovery is anticipated within 3-4 months.
- Relevant referrals, e.g., to rheumatology, physiotherapy, pain management, etc.: Referral to paediatric physiotherapy for post-cast rehabilitation.
Additional Notes:
- Patient education on the diagnosed condition, surgical procedures, potential complications, and the importance of rehabilitation and adherence to post-operative care: The patient's mother was counselled regarding the nature of the Salter-Harris Type II fracture, the rationale for surgical intervention, and the expected surgical procedure. Potential risks such as infection, nerve damage, growth arrest, and re-displacement were discussed. Emphasis was placed on the importance of strict cast care, pain management, and adherence to the physiotherapy regime for optimal outcome.
- Instructions for pre-operative and post-operative care, including activity restrictions, wound care, signs of complications to watch for: Pre-operative instructions include NPO after midnight. Post-operative care instructions include keeping the cast dry and clean, elevating the hand to reduce swelling, and monitoring for signs of infection (e.g., fever, excessive pain, redness, discharge) or neurovascular compromise (e.g., numbness, tingling, excessive swelling, inability to move fingers). Activity restrictions include no sports or heavy lifting for 6-8 weeks post-surgery.
- Any specific patient or family concerns addressed during the consultation: Mother expressed concerns about the recovery time impacting Liam's participation in school sports. Reassurance was provided that with proper adherence to the rehabilitation plan, he should make a full return to activity.
- "After a discussion of the risks, benefits and alternatives, the family wishes to proceed with surgery"
CPT Coding Recommendation: 25607 (Closed treatment of distal radial metaphyseal fracture with percutaneous skeletal fixation, > 7 years of age).
Chief Complaint:
[Chief complaint] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Date of Surgery: [Date of surgery (MM/DD/YY: surgery/procedure with correct laterality)] (Please include in this format. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Date of Injury: [Date of injury (MM/DD/YY: injury description with correct laterality)] (Please include in this format. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
History of Present Illness:
[patient name], a [age]-year-old patient, is accompanied by [parent/guardian relationship] for evaluation of [injury description with laterality]. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) The mechanism of injury was [detailed description of how injury occurred]. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) The patient initially sought treatment at [location of initial treatment] where they received [specific initial treatment such as splint, brace, cast, or other intervention]. (If our office is the place of initial evaluation, omit this sentence entirely. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [referring provider or entity] referred the patient to our office for further evaluation. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) This is [patient's first significant orthopaedic injury/not the patient's first orthopaedic injury]. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Parent/guardian presence and contribution] (If a parent or guardian is present, include a sentence noting their presence and that they were contributory historians. 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 multiple examinations are listed 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 next 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. If the phrase “Upper extremity neurovascularly intact” is mentioned, transcribe 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 the phrase “Lower extremity neurovascularly intact” is mentioned, transcribe 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.” Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
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.)
- [In-office x-rays] (For x-rays obtained in the office today, include the following sentence with the appropriate body part and correct laterality inserted: "I ordered and independently reviewed x-rays in office of the BODY PART today (final radiologist read is pending at the time of the note). The findings are:" Then list the findings. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Prior imaging studies] (For all imaging studies obtained prior to today's visit, mention where they were acquired—capitalize business names if mentioned—when they were acquired, and your interpretation. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Outside radiologist interpretation] (On a separate line, include what the outside radiologist interpretation was. If no radiology interpretation is available, state that. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
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, including 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 amounts of time are mentioned, such as how many months it will take to recover, include the exact timeframe mentioned. 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.)
- [Additional issue assessment and plan] (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.)
CPT Coding Recommendation: [Provide CPT code(s) with rationale based on: problems addressed during the encounter; data reviewed or ordered (labs, imaging, records); risk level of management decisions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
