General Clerking in Orthopaedics

Posted: November 25, 2011 by gerardloh in Orthopaedics & Traumatology

 Ortho General Clerking


a/r/s:  age-race-sex

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

eg: 1) HPT, controlled?, duration, meds, follow up

2) DM, controlled? Duration, meds, follow up…

Refered from?

c/o: pain….etc

Duration : 1 hour

HOPI:  short story about problem
eg: Alleged MVA (MB vs car) at Pandan Indah roundabout, at 7pm. Pt was pilon rider….etc
Fell on right side and sustained immediate pain in right elbow.

Past Medical Hx:

Medications:

Surg Hx:

Social Hx: smoker, alcoholic, occupation, living environment


Systemic review

General : Alert, conscious, Vitals….
CVS:
DRNM

Chest: Lungs Clear

Abdomen: soft, non-tender


Musculoskeletal

Inspection:
Swelling, pain, redness..etc

Power 5/5
ROM
Motor and neuro sensations intact
Pulses: DPA/PTA (LL)     or        Radial/Ulnar (UL)
CRT <2sec

*ABSI (LL): Left and Right foot (in ward)

Radiology:  xray of___ : no OM changes, no gas shadows
Impression (dx): cellulitis of right leg

Plan:

__________________________________________________________________________________________

Orthopedic Progress notes
(A)   

<AM/PM/Night/ Post Op / clinic review>

a/r/s:

k/c/o:

Problem:  Fracture of femur…

________________

(Post op)
Pre Op Dx

POD_ (day/hours):

PODX:

Findings:

_________________

(B)
Progress:
comfortable in bed
pain tolerable

NIL issues

Oral intake well

afebrile

o/e:

Alert, conscious,

non tachypneic

hydration fair

WI: clean, no pus or discharge, no slough, no active bleeding

Vitals: BP, T, PR, SpO2

Plan:

____________________________________________________________________________________

History of presenting illness

1) Trauma

Came unaided? Crutches/Wheel chair?

Alleged____ (MVA, sports injury, fall etc) time____,

Mechanism of injury ( hand outstretched/ flexed, part contacting surface..etc)

Sustained immediate pain

With bleeding? Open wound? LOC? Swelling? Nausea & Vomiting?

Spinal – PU or BO normal?

 

2) DFU

DM duration? control? Medications, follow up clinic

signs of DM complications – retinopathy, nephropaty, neuropathy

Ulcer size, slough, pus, bleeding, signs of ifxn

Neuro sensation and motor

Family support

Ix: Xray- OM changes?

3) Abscess/cellulitis

Size (in cm) Swelling? Erythema? Discharge? Pain? Warm? fluctuant? Firm? Mobile?

Fever? Discolouration?
Trauma or Insect Bite

 ______________________________________________________________________________

Plan

1) DM – DFU

– Duration- F/up clinic- Insulin/OHA

– ABSI in ward

– random glucose, FBS, DXT stix –
– DXT monitoring BD,TDS,QID

– Xray (DFU-OM changes, gas shadow)

– Antibiotics+bactigrass dressingàWDàAmputationàRayàAKA/BKA

2) UL/LL Fractures

– Xray – conservative/manipulation/surgical intervention

a) closed manual reduction
CMR + POP, back slab, splint

– post CMR POP Xray

– 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

– screening test

– PU/BO (PR tone exam)

– stabilization by soft neck brace/ juwet’s brace / body cast

4) Infected wound, cellulitis, abscess
– swab C & S
– antibiotics – Cloxa + C Pen
– PCM
– dressing NS + Bactigrass
– I & D (abscess), saucerisation (carbuncle)

________________________________________________________________________________________

Physical Examination

Swelling and wound

Sensation and motor

ROM

Pulses

CRT


Upper Limbs

Sensations:

Ulna = Little finger – ½ ring finger

radial = dorsal btwn thumb-index finger, post-medial forearm, Triceps

median = thumb- ½ ring finger

musculocutaneous = regimental badge

Motor components
a) Ulna: abduction fingers, thumb to little finger
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)
Plantar: Sural (lat), Lateral Plantar (lat), Medial plantar (med), saphenous(med), calcaneal (heel)

Motor components

a) Iliopsoas = flex thigh at hip against resistance (knee 90degrees)

b) Quadriceps femoris (femoral) = extend leg against resistance (flex-straighten leg)

c) Adductors (obturator) = Adduct limb against resistance

< to be continued…neck and spinal traumas >

all info above are based on my documentation while working in Hospital Ampang….hopefully this may guide you in your Ortho rotation…more to come soon…

Comments
  1. jothi says:

    thanks….its was very helpringfull…i realy appreciate you work…pls update about …LA BLOCKS…. ring block.ankle block,wrist block…

  2. Gheeta says:

    Thank u so much Dr. gerard. Your guide has been so helpful in my first posting. God Bless.🙂

  3. Dr F says:

    Thanks dude… really appreciate even im in my senior era….

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