MSK – Trauma, Fx, Sprain

HISTORY:
provided by patient provided by family member SO/family member present during visit chaperon/MA present during visit interpretation provided by family member/SO interpretation provided by MA complete history unobtainable d/t poor effort/affect complete history unobtainable d/t cognitive changes or lack of knowledge complete history unobtainable d/t language skills

CC:
pain tenderness swelling locking catching giving way bruising cut abrasion unable to bear wt/apply axial pressure distal weakness distal numbness/sensory loss distal pallor/cyanosis

LOCATION:
left right first second third fourth fifth proximal distal upper lower medial lateral dorsal ventral midline

STATED CAUSE:
MVA fall assault sports injury work injury fall near-fall direct blow crush jam twisting lifting bending inversion eversion abduction hyperflexion repetitive injury

HPI:
happened just prior to arrival happened today happened yesterday happened days ago pain at rest pain with use felt snap sensation felt pop sensation felt crack sensation sx increasing in severity sx remaining constant sx decreasing in severity

PREVIOUS EVALUATION:
none ER UC XR CT

PMSH:
noncontributory head injury previous injuries back pain migraine chronic pain meds diabetes PAD immunosuppression

REVIEW OF SYSTEMS: [+] reported [-] not reported
negative except as stated in HPI

CONSTITUTIONAL:

objective fever subjective fever chills
EYES:

change in vision photophobia periorbital swelling pain with EOM
EARS:

pain bleeding tinnitus decreased in hearing
NOSE:

discharge snoring bleeding
MOUTH/THROAT:

bleeding tongue pain/swelling sore throat odynophagia dysphagia hoarseness
NECK:

pain stiffness swelling swollen glands
CV:

chest pain/pressure dyspnea orthopnea ankle swelling ankle discoloration leg cramps
CHEST/RESPIRATORY:

chest tightness pain w/ breathing rib pain cough
GI:

poor appetite nausea vomiting abdominal pain constipation diarrhea
GU:

dysuria hematuria retention oliguria incontinence genital lesions/discharge
NEURO:

dizziness vertigo poor balance abnormality of walk focal weakness blackouts seizures tingling/numbness
PSYCH:

irritability confusion depression anxiety mood swings memory loss insomnia
LYMPH/HEMA:

gland swelling bruising anticoagulation DVT/clotting anemia autoimmune dz h/o cancer
DERM:

dryness pruritus rash hives redness swelling wounds new or suspicious lesions

Appearance:
well-appearing alert allows exam crying but consolable no apparent distress while getting on/off exam table & walking around exam room ill-appearing diaphoretic guarding poor cooperation with exam drowsy appears impaired slumped

Skin:
warm, dry grossly intact, no rashes normal turgor tattoos body piercings pallor cyanosis poor turgor diaphoresis rash

Head/Face:
normocephalic no evidence of trauma no facial tenderness symmetrical face CN grossly intact

Eyes:
clear conjunctiva w/o exudates or hemorrhage, EOM intact without nystagmus visual acuity grossly intact cornea(s) clear glasses contacts conjunctival injection epiphora periorbital swelling dysconjugate gaze

Ears:
symmetrical & intact auricles bilaterally hearing to conversation intact clear canals without erythema or blood TMs normal in appearance

Nose:
nares patent bilaterally septum midline mucosa pink & moist mucosal edema clear discharge active septal hemorrhage dried up blood

Mouth/Throat:
normal voice moist oral mucosa without lesions or injury patent pharynx w/o swelling or exudates hoarseness tooth decay upper denture lower denture pharyngeal erythema w/o exudates pharyngeal crowding tonsillar enlargement

Neck:
symmetric with free painless ROM no LAD anterior LAD posterior LAD nuchal tenderness

Chest/Lungs:
normal work of breathing, symmetrical chest expansion chest wall atraumatic and non-tender clear and equal breath sounds bilaterally poor effort coughing

CV:
regular rhythm no murmurs no ankle edema pedal skin warm with good & equal pulses tachycardia irregular heart rhythm murmur calf tenderness ankle edema varicosities stasis discoloration

Abdomen:
not examined normal visual inspection, no distension normal active bowel sounds soft non-tender protruding surgical scar umbilical hernia diffuse tenderness over entire abdomen w/o RRG

GU:
not examined no suprapubic tenderness no CVAT bilaterally normal external genitalia no inguinal LAD

Neuro:
oriented to person, place, time normal concentration and attention memory grossly intact ambulates w/o limp or alteration in gait balance & coordination grossly intact extremities strong w/o atrophy, tremor or fasciculations antalgic gait wide gait shuffling gait dystonia

Behavior:
calm, pleasant, respectful allows exam cooperative with exam poor cooperation with exam guarded anxious fearful suspicious hypervigilant irritable frustrated restless labile sighing crying agitated raising voice defensive argumentative hostile forceful intense euphoric demanding particular medication, test, referral, or accommodation withdrawn indifferent appears to be responding to internal psychotic process

Psychomotor Activity:
no involuntary movements tremor tardive dyskinesia tics bradykinetic fidgeting picking skin twirling hair cracking knuckles threatening posture/movement grimacing, furrowing eyebrows tightening jaw breathing hard shaking extremities clenching fists intense staring standing up and/or pacing opening door to hallway exited exam room during exam

Speech/Vocalization:
normal for age clear & coherent slurred monotonous stuttering hypoverbal hyperverbal loud soft slow rapid pressured repetitive questions cursing, swearing criticisms of staff verbal threats

Injury Site inspected, observed in active ROM, & palpated:
no gross deformity or misalignment joints above & below affected area intact deformity warmth, swelling, tenderness pain with axial loading DROM joint laxity skin intact abrasion laceration bruise

Sensory:

thumb web space (radial) tip of index finder (median) tip of little finger (ulnar) big toe web space (deep peroneal) sole (post tibial) lateral dorsum of foot (superficial) UE LE

Vascular:
UE cap refill brisk bilaterally, pulses strong & equal LE cap refill brisk bilaterally, pulses strong & equal

Motor:

wrist extension (radial) finger flexion/thumb opposition (median) finger abduction/adduction (ulnar) ankle eversion (superficial peroneal) ankle dorsiflexion (deep peroneal) ankle/toe flexion (tibial) UE LE

OFFICE X-RAYS:

none essentially normal no fx transverse fx oblique fx spiral fx comminuted fx extra-articular fx intra-articular fx angulation present translation present shortening present rotation present dislocation present staff to notify patient once radiology report becomes available

A/P:

PLAN OF CARE:
POC risks/benefits/alternatives discussed with patient/parent/SO, opportunity provided to ask questions verbalized understanding that X-rays reviewed online not diagnostic quality verbalized understanding that normal X-rays do not exclude non-displaced fracture verbalized understanding of and agreement with POC, discharge & f/u instructions did not agree with my POC/recommendations – will seek second opinion/further care elsewhere

TREATMENT:
immobilization provided applied compression bandage/sleeve brace applied splint applied immobilized with boot orthosis immobilization with post-op shoe provided with crutches provided with sling placement, alignment, & N/V status verified tetanus vaccination per facility protocol

RX:
none electronic paper given to MA to be transmitted to pharmacy

REVIEWED:
MA notes med list previous visits PMP/CURES previous laboratory studies previous diagnostic studies specialty reports hospital discharge

VERBALLY INSTRUCTED ON:
vital signs/exam findings/recommendations x-ray findings RICE regimen x 72 hrs — rest, ice, compression, and elevation OK to perform contrast baths after 72 hrs early ROM exercise/stretching to prevent deconditioning appropriate follow up with ortho regardless of X-ray findings reporting medication side effects immediately splinting until cleared by ortho non-weight bearing with crutches until cleared by ortho check for N/V integrity of affected part contact emergency services if increased swelling/pain/numbness/tingling of affected extremity, trouble moving fingers/toes, fingers/toes turning cold/blue/grey lifting techniques controlling chronic conditions cognitive restructuring symptom exacerbation through rebound mechanism risks of respiratory depression a/w meds

BARRIERS TO CARE:
none identified poor cooperation with exam lack of motivation negative attitude to diagnostic impression & proposed tx incomplete history vague shifting complaints history not supported by objective findings poor compliance with POC multiple comorbidities polypharmacy lack of interest in nonpharmacologic therapies overwhelming focus on Rx drugs intolerance of multiple meds frequent ER/UC visits altered mental status hostile/disruptive behavior active psychiatric diagnosis alcohol or substance use social/cultural barriers victim of abuse perseveration flight of ideas preoccupation with illness catastrophization overgeneralization unrealistic beliefs negativism pessimism blaming others staff splitting

DISCHARGE CONDITION:
improved stable unchanged

WORK/SCHOOL STATUS:
N/A fit for duty w/o restrictions as of fit for duty with restrictions no kneeling/squatting/climbing ladders avoid prolonged sitting avoid prolonged standing avoid strong gripping with hands avoid repetitive hand movements no lifting over 25 lbs no pushing/pulling over 50 lbs no PE/gym excuse provided

DISPOSITION:
RTC as discussed, sooner if condition worsens or new symptoms arise, contact 911/ER if significant increase in s/sx or appearance of new/danger s/sx RTC 48 hours to 72 hours RTC 1 week ortho within 3 days ortho within 1 week referred to ER for immediate treatment via 911 referred to ER for immediate treatment via private transport declined emergency transfer left facility before being discharged asked to leave clinic

MSK – Trauma, Fx, Sprain

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