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Ortho Clerking

This document provides a template for orthopedic general clerking and progress notes. It includes sections on the patient's age, race, sex, chief complaints, past medical history, medications, surgical history, social history, history of present illness, physical examination findings, radiology results, impression, and treatment plan. The physical examination section focuses on inspection, range of motion, motor and sensory functions, pulses, and relevant orthopedic tests. Common orthopedic conditions like fractures and diabetic foot ulcers are discussed.

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Nur Liyana Ahmad Zaki
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480 views4 pages

Ortho Clerking

This document provides a template for orthopedic general clerking and progress notes. It includes sections on the patient's age, race, sex, chief complaints, past medical history, medications, surgical history, social history, history of present illness, physical examination findings, radiology results, impression, and treatment plan. The physical examination section focuses on inspection, range of motion, motor and sensory functions, pulses, and relevant orthopedic tests. Common orthopedic conditions like fractures and diabetic foot ulcers are discussed.

Uploaded by

Nur Liyana Ahmad Zaki
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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General Clerking

Systemic review

in Orthopaedics
General : Alert, conscious, Vitals….
CVS: DRNM
Ortho General Clerking
Chest: Lungs Clear

a/r/s: age-race-sex Abdomen: soft, non-tender

K/c/o : Disease – Duration – medication –


follow up Musculoskeletal

eg: 1) HPT, controlled?, duration, meds, Inspection:


follow up Swelling, pain, redness..etc

2) DM, controlled? Duration, meds, follow Power 5/5


up… ROM
Motor and neuro sensations intact
Refered from? Pulses: DPA/PTA (LL) or Radial/Ulnar
(UL)
c/o: pain….etc
CRT <2sec
Duration : 1 hour
*ABSI (LL): Left and Right foot (in ward)
HOPI: short story about problem
Radiology: xray of___ : no OM changes, no
eg: Alleged MVA (MB vs car) at Pandan
gas shadows
Indah roundabout, at 7pm. Pt was pilon
Impression (dx): cellulitis of right leg
rider….etc
Fell on right side and sustained immediate Plan:
pain in right elbow.
____________________________________
Past Medical Hx: ____________________________________
__________________
Medications:

Surg Hx:

Social Hx: smoker, alcoholic, occupation,


living environment
Orthopedic Progress notes Plan:
(A)
____________________________________
<AM/PM/Night/ Post Op / clinic review> ____________________________________
____________
a/r/s:
History of presenting illness
k/c/o:
1) Trauma
Problem: Fracture of femur…
Came unaided? Crutches/Wheel chair?
________________
Alleged____ (MVA, sports injury, fall etc)
(Post op)
time____,
Pre Op Dx
Mechanism of injury ( hand outstretched/
POD_ (day/hours): flexed, part contacting surface..etc)
PODX: Sustained immediate pain
Findings:
With bleeding? Open wound? LOC?
_________________ Swelling? Nausea & Vomiting?

(B) Spinal – PU or BO normal?


Progress:
comfortable in bed
pain tolerable 2) DFU

NIL issues DM duration? control? Medications, follow


up clinic
Oral intake well
signs of DM complications – retinopathy,
afebrile nephropaty, neuropathy
o/e: Ulcer size, slough, pus, bleeding, signs of
Alert, conscious, ifxn

non tachypneic Neuro sensation and motor

hydration fair Family support

WI: clean, no pus or discharge, no slough, Ix: Xray- OM changes?


no active bleeding 3) Abscess/cellulitis
Vitals: BP, T, PR, SpO2
Size (in cm) Swelling? Erythema? Discharge?
Pain? Warm? fluctuant? Firm? Mobile?
Fever? Discolouration? - screening test
Trauma or Insect Bite
- PU/BO (PR tone exam)
___________________________________
- stabilization by soft neck brace/ juwet’s
____________________________________
_______ brace / body cast

Plan 4) Infected wound, cellulitis, abscess


– swab C & S
1) DM – DFU – antibiotics – Cloxa + C Pen
– PCM
- Duration- F/up clinic- Insulin/OHA
– dressing NS + Bactigrass
- ABSI in ward – I & D (abscess), saucerisation (carbuncle)

- random glucose, FBS, DXT stix -


– DXT monitoring BD,TDS,QID ____________________________________
____________________________________
- Xray (DFU-OM changes, gas shadow) ________________

- Antibiotics+bactigrass Physical Examination


dressingàWDàAmputationàRayàAKA/BKA
Swelling and wound
2) UL/LL Fractures
Sensation and motor
- Xray – conservative/manipulation/surgical
intervention ROM

a) closed manual reduction Pulses


CMR + POP, back slab, splint CRT
- post CMR POP Xray Upper Limbs
- 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
Sensations: Plantar: Sural (lat), Lateral Plantar (lat),
Medial plantar (med), saphenous(med),
Ulna = Little finger – ½ ring finger calcaneal (heel)
radial = dorsal btwn thumb-index finger,
Motor components
post-medial forearm, Triceps
a) Iliopsoas = flex thigh at hip against
median = thumb- ½ ring finger resistance (knee 90degrees)
musculocutaneous = regimental badge b) Quadriceps femoris (femoral) = extend
Motor components leg against resistance (flex-straighten leg)
a) Ulna: abduction fingers, thumb to little
c) Adductors (obturator) = Adduct limb
finger against resistance
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)

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