Trauma clinic

Chief Complaint

Follow-up for fracture management.

Template

Verbal consent obtained for the use of AI scribe tool. Although reasonable efforts are made to proofread, some transcription errors may persist. Diagnosis: [] Prior Treatment: [casting, closed reduction and casting, closed reduction and percutaneous pinning, open reduction and percutaneous pinning, Open reduction and percutaneous pinning] Date of injury: [date and include how many weeks ago] Mechanism of Injury: [fall off height, fall off monkey bars, fall onto outstretched hand, fall off bike, pushed while playing hockey, fall of bicycle, motor vehicle collision, struck by vehicle as a pedestrian, trampoline injury] Pmhx: [Healthy, no prior fractures] Medications: [No regular medications] Activities: [] History: [] Physical Exam: (currently in well-fitted cast, cast removed skin tact, cast removed some skin irritation, cast removed pins sites covered by bandage, cast removed incision clean and dry, no obvious deformity, mild deformity noted at fracture site) (no tenderness to fracture site, tenderness to fracture site, mild tenderness to fracture site) (range of motion not tested, range of motion full and symmetric with contralateral side, range of motion limited) Neuro: (Normal sensation to radial, ulnar, and median nerve distributions. Normal power with thumb extension, FDP flexion, and finger abduction. Pulses intact, good cap refill.) (Normal sensation to deep peroneal, superficial peroneal, tibial, sural, and saphenous nerve distributions. Normal great toe extension, ankle dorsiflexion, ankle plantar flexion, and foot eversion. Pulses intact, good cap refill.) (Not compliant with thorough neurovascular exam, but seen to be moving limb. No deficits noted by parents.) Imaging: (xrays of the site of xray ie distal forearm, elbow, etc) (Fracture united with acceptable alignment, Ongoing healing at fracture site with acceptable alignment. Fracture line still visible, Ongoing healing at fracture site. Some loss of alignment, Aligment unchanged, hardware position acceptable, Loss of alignment, hardware failure) Plan: [] Follow-up: [] _