Clerk New Case : Ortho

1. 47yo/malay/male
2. NKMI: No Known Medical Illness or
    U/L (Underlying Disease) : DM, HPT, Dyslipidemia, CCF (Congestive Cardiac Failure)

3. P/W (Presented with) or Presented with
  - Alleged MVA, MB vs Car at Skudai ~ 7:30 pm 18/2/2016 + helmet, around 60km/h
      -Mechanism of Injury: Claimed another car hit his MB from left side & pt felt on his right side
        car hit from ?
        fell on ? site
        thrown to longkang?
  - Fall from height
     - Mechanism of injury
  - Swelling over lateral aspect left thigh
  - Pain over lumbosacral region
SOCRATES

1. Site - Where is the pain? Or the maximal site of the pain.
2. Onset - When did the pain start, and was it sudden or gradual? Include also whether if it is progressive or regressive.
3. Character - What is the pain like? An ache? Stabbing? Cramping?
4. Radiation - Does the pain radiate anywhere? (See also Radiation.)
5. Associations - Any other signs or symptoms associated with the pain?
6. Time course - Does the pain follow any pattern?
7. Exacerbating/Relieving factors - Does anything change the pain?
8. Severity - How bad is the pain?

PQRST

1. P = Provoking factors (what brought on the pain?); 
2. Q = Quality (describe the pain- i.e. stabbing, throbbing, burning); 
3. R = Radiation (does the pain radiate anywhere?); 
4. S = Severity/symptoms (how bad is the pain- rate it; are there other symptoms with the pain?); 
5. T = Timing (is it constant? What makes it better/worse?) 

4. Post Trauma

  - c/o pain at - Right forearm
                      - Shoulder & back
  - LOS?

  - RA (Retrograde Amnesia)
  - PU (Urin)/BO (Bowel Output)
  - Nausea/Vomitting
  - headchae?
  - chest pain? abd pain?
  - SOB
  - CNS Injury: Racoon eyes, BAttle Sign,
  - ENT BLeeding
  - Fever
  -Meds
  - Able to Ambulate well post RTA

5. PMHx
6. PSHx
7. Allergy & LAst Meal
8. Drugs Hx:
9. Social Hx: Smoker? Drugs? Sexual? Alcohol? MArried? Work as?
5. O/E (On Examination)
    - Alert< Conscious, GCS: EMV
    - V/s:
    - Lungs: Clear/Bilateral Crepitations/ Ronchi
    - CVS: DRNM (Dual Rhythm No Murmur)
    -P/A : SNT (Soft Non Tender)

Orthopaedic examination of_a_patient from Mohammed Azharuddin


Head to Toe
Head: Scalp Hematoma, Racoon, Battle, Wound
NEck: ROM, Cervical tenderness, NEck stiffness
Chest: Chest Spring -, Equal A/E
Pelvic Spring
ROM for arms and limb, CRT, warm peripher
DPA/PTA, Radial Pulse
PR: Intact anal tone, PR bleed -
able to move all toes
CRT
ASIA
Spine Palpation: TEnderness, Swelling, PAin
Wound: Type , Size , Location ... abrasion wound , deep laceration 3 cm with bone exposed

Findings~
Lab
X-Ray
Magnetic resonance imaging (MRI):
An MRI can identify stress fractures. It's also very useful to identify soft tissue injuries, such as:
• Muscle tears
• Hematomas
• Ligament injury
• Spinal structures
• Meniscal injury
• Tendon ruptures
• Degenerative problems
• Tumors


Again Age/Race/GEnder
Impression: Allged fall blablabla