Trauma Note

Occupation:
Sport:
Chief Complaint:
Involved Side:
Injury:
HPI: 25y/o female (describe location, time, associated factors in injury)
Quality:
Associated Symptoms:
Severity/Timing:
Duration:
Context:
Modifying factors:
Previous treatment: NSAIDs, no injections, no brace, no PT, no surgeries, does not use any assistive devices. .
PMH:none
PSH:none
Family History: patient questionaire was reviewed in the chart and was signed and dated and is noncontributory.
Medications: none
Allergies: none
SH: no tob, no ETOH, married.
ROS: Patient questionnaire was reviewed, signed and dated. Pertinent findings: no fevers, no chills, no drastic changes in weight, no metal known metal allergies.
PHYSICAL EXAM
HT: Wt: Pulse:
General Appearance: well-nourished, well-developed, mild distress. Appears stated age.
Orientation: AO x 3
Mood / Affect: calm
Gait: normal
Skin: normal, no scars
Lymph: no edema, no lymphadenopathy
Cervical Spine
Flexion: 45
Extension: 45
Lateral Bend(R/L): 45 /45
Rotation (R/L): 80 / 80
Spurling’s test positive (R/L): - / -
C5 (Deltoid / lateral arm sensation / Biceps)= 5/5 : normal / 2+
C6 (Wrist Extension / Lateral forearm sensation / Brachioradialis)= 5/5 : normal : 2+
C7 (Triceps / Middle finger sensation / Triceps reflex)= 5/5 : normal : 2+
C8 (Interossei / ulnar forearm)= 5/5 : normal
T1 (Interossei / Medial arm)= 5/5+ : normal
Waddell Signs: -tenderness, -simulation, -distraction, -regional disturbances, -overreaction
Clonus (R/L): - / -
Babinski (R/L): - / -
Radial Pulse (R/L): 2+ / 2+
Shoulder
Inspection: shoulders symmetric, no atrophy, no scars bilateral upper extremities.
Palpation: no AC tenderness bilaterally.
Active Forward Elevation (R/L): 160 / 160
Passive Forward Elevation (R/L): 160 / 160
External Rotation at side (R/L): 50 / 50
Internal Rotation (R/L): T9 / T9
Cross Arm (R/L): - / -
Neer (R/L): - / -
Hawkins (R/L): - / -
Scapulothoracic motion (R/L): 2:1 / 2:1
O'Brien (R/L): - / -
Yergusons (R/L): - / -
Speeds (R/L): - / -
Sulcus (R/L): - / -
Apprehension (R/L): - / -
Generalized ligamentous laxity: none
C-spine: non-tender, full ROM
Abduction: 5/5 External Rotation: 5/5 Internal Rotation: 5/5
Biceps: 5/5 Triceps: 5/5 Wrist Extension: 5/5 Wrist Flexion: 5/5 Interosseous: 5/5
subjective normal m/u/r/ax sensation
2+ radial pulse
Elbow
Tenderness: lateral epicondyle reproduces pain
Resisted wrist and finger extension with the elbow in full extension exacerbates pain
No pain on resisted suppination (PIN irritation).
ROM (R/L): 0-135 / 0-135
Suppination (R/L): 80 / 80
Pronation (R/L): 80 / 80
Negative Tinel's at the Cubital tunnel
no generalized ligamentous laxity
No numbness with elbow maximally flexed and wrist extended
Subjective normal M/U/R distal sensation
2+ Radial pulse
Wrist
Tenderness: none
Flexion(R/L): 55 / 55
Extension (R/L): 45 / 45
Radial deviation (R/L): 12 / 12
Ulnar deviation (R/L): 30 / 30
able to A-OK, hook horns, cross fingers, thumbs up
subjective normal M/U/R distal sensation
2+ Radial pulse
Hip
Tenderness: none
Flexion (R/L): 120 / 120
Extension (R/L): 30 / 30
Abduction (R/L): 45 / 45
Adduction (R/L): 25 / 25
Internal Rotation (R/L): 35 / 35
External Rotation (R/L): 45 / 45
No quad tightness
Seated SLR (R/L): - / -
Supine SLR (R/L): - / -
subjective normal distal sensation
5/5 EHL, TA, PF
2+ dorsalis pedis
Knee
Inspection/Palpation: non tender
Alignment (R/L): 4 valgus / 4 Valgus
Effusion (R/L): none / none
ROM (R/L): 0-130 / 0-130
Varus laxity (R/L): 0+ / 0+
Valgus laxity (R/L): 0+ / 0+
Posterior Drawer (R/L): 0+ / 0+
Lachman (R/L): 0+ / 0+
Pivot shift (R/L): 0+ / 0+
McMurray (R/L): - / -
No quad tightness
Lateral patellar tracking with deep knee bend. Notes anterior knee pain at 45-90 degrees of deep knee bend.
no apprehension
no generalized ligamentous laxity
subjective normal distal sensation bilaterally
5/5 EHL, TA, PF bilaterally
Dorsalis pedis (R/L): 2+/2+
DTR (R/L): Biceps (2+/2+); Triceps (2+/2+) Patellar (2+/2+); Achilles (2+/2+)
Ankle
Tenderness: none, no proximal tenderness
Hindfoot Alignment (R/L): neutral / neutral
Effusion (R/L): none / none
Dorsiflexion (R/L): 30 / 30
Plantar flexion (R/L): 50 / 50
Anterior Drawer in plantar flexion (R/L): 0+ / 0+
Anterior Drawer in dorsi flexion (R/L): 0+ / 0+
Lateral Talar tilt (R/L): 0+ / 0+
Medial Talar tilt (R/L): 0+ / 0+
subjective normal distal sensation
5/5 EHL, TA, PF
2+ dorsalis pedis
Xray: Mild lateral patella tilt. The osseous structures are otherwise intact without fracture, dislocation or evidence of arthritis.
MRI: none
ASSESSMENT:
Discussed natural history, operative and non-operative treatments; risks, benefits and expected rehab course of each. All questions answered.
Physical Therapy
Brace / splint
Pre-op clearance
NSAIDS
Information sheet given
Follow-up 6-8 weeks