Monday, 18 April 2016

AM/PM/ON Review

<AM REVIEW>
47yo/malay/male
+ smoke
U/L:

▲ Open fracture distal Right radius 
    -POD2 Plating ↓ (under) GA
    -PTD4: alleged MVS (MB vs CAr), pt fall blablabla
▲ 


OR

▲ B/L knee pain x 4/12 worsen for past 2/52 
     wheelchair ambulation due to pain
    pain aggravates on standing, walking
     relieved by rest


Currently pt appears: stable, comfortable,


c/o Pain over b/l knee more on left side, afebrile, no sob, no chest pain, no urti, nil symptom, PU present, tolerat orally


o/e:
-alert
-conscious
- no tachypnoe
-not tachycardic
v/s
lungs: clear
cvs: s1s2 heard, no murmur
P/A: soft non tender

Examintaion on b/l lower limb
- dressing soaked?
- swelling?
-tender?
-wound clean?
CRT?
DPA, PTA?
ROM
Sensation
erythematous
warm

Lab:
Xray
USG:


Plan
1.


Analgesics


Antibiotics

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