Menu  Search

House Officers Workshop Malaysia

Work and share, together we learn!

General Clerking in Orthopaedics

Posted by gerardloh

3 Votes

 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…

Share this:

 Twitter  Facebook

Like
Be the first to like this.

Related

Obstetrics Clerking History taking ST SEGMENT

In "O & G" In "Medicine" ELEVATED
MYOCARDIAC
INFARCTION (STEMI)
In "Medicine"

November 25, 2011  4 Replies

 « Previous Next »

Leave a Reply
Your email address will not be published. Required fields are marked *

Comment

Name

*
Email

*
Website

Post Comment

Notify me of new comments via email.

Notify me of new posts via email.

jothi on December 24, 2011 at 11:31 am

thanks….its was very helpringfull…i realy appreciate you work…pls update

about …LA BLOCKS…. ring block.ankle block,wrist block…

 Reply

gerardloh on August 17, 2012 at 11:47 am

 thanks for your suggestions, I did a section about blocks…download the
ortho HO guide..u will find it there

 Reply

Gheeta on December 17, 2014 at 10:12 am

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

 Reply

Dr F on September 13, 2015 at 5:54 pm

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

 Reply

Categories

A&E
Clinical Examination Workshop
Courses
Medicine
O&G
Orthopaedics & Traumatology
Paediatrics
Primary Care
Storyboard
Surgery
Uncategorized

Recent entries

Surviving Medicine
Primary Care QR
KKIA Guide
Acknowledgements
Key summary of Saturday Teach-in Difficult Dengue 13/9/14
Top Posts

HO Guide
Downloadable reading materials
Orthopedics Guide
Surgical HO Guide
HOW Guides

Archives

October 2018
September 2018
July 2015
October 2014
September 2014
April 2014
November 2013
June 2013
May 2013
March 2013
February 2013
November 2012
October 2012
September 2012
June 2012
May 2012
February 2012
January 2012
December 2011
November 2011
September 2011
August 2011
April 2011
January 2011
December 2010
November 2010
October 2010
September 2010
July 2010

Search

Crimea How
Join us on facebook!

Our authors

chao85

gerardloh

kiamseong

smarinz7

yongchieh

View Full Site

Blog at WordPress.com.