骨科標準病歷範本
一.【ACL】
Chief Complaint: Lt. knee pain with sensation of giving way for at least 2 years.
Present Illness:
This 27-year-old male patient is a soccer player. He injured his Lt. knee joint in a match some 2 years ago. There was immediate swellingin the joint and it lasted for a month. Since then, he frequently has a catching sensation in the joint with pain felt. A frequent giving way sensation was also felt. He had an MRI exam. done at Chang-Gung hospital which showed tear of the ACL.
The patient came to our OPD. Physical exams led to the impression of Lt. knee ACL and med. meniscal tear and the patient was admitted to our ward for surgical intervention.
Past History:
1.DM:-
2.Hypertension:-
3.Gout:-
4.Operation:-
5.Drinking:-
6.Smoking:-
7.Betle Nut:-
Allergy:-
Family History: Non-contributory
1.DM: Father:- Mother:-
2.Hypertension: Father:- Mother:-
3.Gout: Father:- Mother:-
4.other systemic disease:-
Review of Systems:
General appearance: fever (-), anorexia (-), body weight loss (-)
Head and Neck: headache (-), sorethroat (-), rhinorrhea (-), blurred vision (-)
Chest: chest pain (-), dyspnea (-), cough (-) hemoptysis (-), sputum (-)
Abdomen: vomiting (-), diarrhea (-), flank pain (-), constipation (-), stool incontience (-)
GU/GYN: dysuria (-), hematuria (-), nocturia (-), urinary incontience (-)
Physical Examinations:
Skin:normal tension, not dehydrated
Consciousness:clear, alert
Head: no trauma, no scar.
Pupils: Isocoric, light reflex:+, prompt
Conjunctiva: not pale. Sclera: not icteric.
Neck: Supple, no LN is palpable
Chest: Symmetric expansion, breathing sound is clear
Heart: regular heart beat. No gallop. No bruit. No murmur.
Abdomen; Flat, Solt, liver and spleen are not palpable
no muscle guarding, no rebounding pain, no palpable mass,
bowel sound: acoustic, normoactive
Local findings: R't L't
Genu Varum: - -
Range of motion: 0-145 0-145
P-F Grinding pain: - -
Reticulum Med. - -
Tenderness: Lat. - -
Stress Test: Med.0: - -
30: - -
Lat.0: - -
30: - -
Lachmann - ++
Drawer: Ant. - +++
Post. - -
Pivot Shift: - ?
Joint line tenderness
Med. - +
Lat. - -
McMurray: Med. - +
Lat. - -
Condyle Tenderness:
Med. - -
Lat. - -
Others:
Laboratory Data:
Lt. knee MRI: ACL, med. meniscus tear.
Impression:
Lt. knee anterior cruciate ligament, med. meniscus tear.
Plans:
Op.: Arthroscope examination, ACL-R, partial meniscectomy, debridement.
Post-op care, rehab.
二.【Knee Injury】
Chief Complaint: Lt. knee pain for more than 18 months.
Present Illness:
This 69-year-old male patient had a motorcycle accident some 18 months ago. His Lt. knee and lower leg were injured and were managed by bonesetters for a period of time. His Lt. knee joint pain has bothered him off and on since then. In recent months the pain has become persistent and has increased in intensity.
The patient came to our OPD. Physical and X-ray exams led to the impression of Lt. knee meniscal tear; MRI exam. showed menisci tear with OA changes of the joint. The patient was admitted to our ward for surgical intervention.
Past History:
1.DM:-
2.Hypertension: noted for years, under regular treatment
3.Gout:-
4.Operation:Cardica cath. due to previous AMI
5.Drinking:-
6.Smoking:-
7.Betle Nut:-
Allergy:-
Family History: Non-contributory
1.DM: Father:- Mother:-
2.Hypertension: Father:- Mother:-
3.Gout: Father:- Mother:-
4.other systemic disease:-
Review of Systems:
General appearance: fever (-), anorexia (-), body weight loss (-)
Head and Neck: headache (-), sorethroat (-), rhinorrhea (-), blurred vision (-)
Chest: chest pain (-), dyspnea (-), cough (-) hemoptysis (-), sputum (-)
Abdomen: vomiting (-), diarrhea (-), flank pain (-), constipation (-), stool incontience (-)
GU/GYN: dysuria (-), hematuria (-), nocturia (-), urinary incontience (-)
Physical Examinations:
Skin: normal tension, not dehydrated
Consciousness:clear, alert
Head: no trauma, no scar.
Pupils: Isocoric, light reflex:+, prompt
Conjunctiva: not pale. Sclera: not icteric.
Neck: Supple, no LN is palpable
Chest: Symmetric expansion, breathing sound is clear
Heart: regular heart beat. No gallop. No bruit. No murmur.
Abdomen; Flat, Solt, liver and spleen are not palpable
no muscle guarding, no rebounding pain, no palpable mass,
bowel sound: acoustic, normoactive
Local findings: R't L't
Genu Varum: - -
Range of motion: 0-145 0-145
P-F Grinding pain: - +
Reticulum Med. - -
Tenderness: Lat. - -
Stress Test: Med.0: - -
30: - -
Lat.0: - -
30: - -
Lachmann - -
Drawer: Ant. - -
Post. - -
Pivot Shift: - -
Joint line tenderness
Med. - +
Lat. - +
McMurray: Med. - +
Lat. - ?
Condyle Tenderness:
Med. - +
Lat. - -
Others:
Lab. Data:
981224
L't knee MRI without Gadolinium, parameter with sagittal ( PD & T2W & PD fatsuppression ), coronal ( PD & PD fat suppression ) and axial ( PD fatsuppression ) show:
IMP:
(1)Horizontal tear at lateral meniscal anterior horn,body and posterior horn.
(2)Horizontal tear at medial meniscal body and posterior horn.
(3)Chronic sprain and tendinosis and thickening of MCL.
(4)Intact ACL,PCL,LCL,,iliotibial band,biceps femoris tendon,popliteus tendon,and Pes anserinus.
Impression: Lt. knee menisci tear.
Plan:
OP: Arthroscope examination, partial meniscectomy, debridement
Post-op care.
三.【Rotator Cuff Tear】
Chief Complaint: Rt. shoulder pain for more than 4 years.
Present Illness:
This 51-year-old female patient has suffered from right shoulder pain for more than 4 years. The pain is much worse during the night and is aggravated when the patient is trying to do overhead activities. Range of motion has insidiously become restricted. Shoulder Index Strength of affected shoulderis much weaker than that of the other one. The patient could not recall any trauma to the affected shoulder. She had MRI exam. done at NCKUH which showed tear of the rotator cuff.
The patient came to our OPD. Physical and X-ray exams led to the impression of shoulder OA, impingement syndrome, and rotator cuff tear. The patient was admitted to our ward for surgical intervention.
Past History:
1.DM:-
2.Hypertension:-
3.Gout:-
4.Operation:-
5.Smoking:-
6.Drinking:-
7.Betle-nut:-
Personal History:
Allergy:-
Family History:
Non-contributory
1.DM: Father:- Mother:-
2.Hypertension: Father:- Mother:-
3.Gout: Father:- Mother:-
4.other systemic disease:-
Review of Systems:
General appearance: fever (-), anorexia (-), body weight loss (-)
Head and Neck: headache (-), sorethroat (-), rhinorrhea (-), blurred vision (-)
Chest: chest pain (-), dyspnea (-), cough (-) hemoptysis (-), sputum (-)
Abdomen: vomiting (-), diarrhea (-), flank pain (-), constipation (-), stool incontience (-)
GU/GYN: dysuria (-), hematuria (-), nocturia (-), urinary incontience (-)
menopause (+)
Physical Examinations:
Skin:normal tension, not dehydrated
Consciousness:clear, alert
Head: no trauma, no scar.
Pupils: Isocoric, light reflex:+, prompt
Conjunctiva: not pale. Sclera: not icteric.
Neck: Supple, no LN is palpable
Chest: Symmetric expansion, breathing sound is clear
Heart: regular heart beat. No gallop. No bruit. No murmur.
Abdomen; Flat, Solt, liver and spleen are not palpable
no muscle guarding, no rebounding pain, no palpable mass,
bowel sound: acoustic, normoactive
Local findings: R't L't
Range of motion:
Abduction 0-150 0-180
For. Flexion 0-150 0-180
Ext. Rotation
Side 30 60
Horizontal 0-140 0-180
Int. Rotation L5 T8
Impingement
Abd. + -
Abd.30 degrees ++ -
Cross-over - -
A-C Tenderness - -
O'Brien's Test - -
M.Power:
Deltoid 5-/5 5/5
Supraspinatus 5-/5 5/5
Ext.Rotator 5-/5 5/5
Orthers:
Laboratory Data:
990120
Rt. Shoulder x-rays: Right subacromion spur formation with OA change.
Rt. Shoulder MRI: rotator cuff tear.
Impression:
Rt. shoulder rotator cuff tear.
Plans:
Operation: Acromioplasty, bursectomy, synovectomy, rotator cuff repair.
Post-op care and rehab.
四.【spine】
Chief Complaint:
The patient is a 76 year-old man with low back painradiating to the left leg for 6-7 months.He visited our OPD.Physical Examination of the lower back showed pain radiating to the left leg with numbness,left leg weakness, dorsiflexion weakenssof the bilateral great toes. SLRT showed (R -/L -). X-ray of spine showed retrolisthesis of L12, L23, and L34 and disc space narrowing at L3-S1.
Claudication < meters
night pain (+ or -)
physical therapy for ( ) months or other treatment
The symptom and sign were worse or off and on or recurrence.
Then he was admitted for further management.
Past History:
1.H/T(+)Tenomin 1#qd, DM(-), Heart disease (-)
2.R't shoulder OA s/p total shoulder replacement on 89-09-08
3.Left shoulder OA s/p total shoulder replacement + tendon release on
90-01-12
4.Bil renal stone s/p ESWL at 奇美醫院
5.BPH s/p TUR-P on 95/08/16
6.Recurrent benign prostatic hyperplsia & bladder neck contracture on
96-11-16.
7.Right femoral head AVN s/p T.H.R.(R) on 97-06-05.
Allergy:-
Family History: Non-contributory
1.DM: Father:- Mother:-
2.Hypertension: Father:- Mother:-
3.Gout: Father:- Mother:-
4.other systemic disease:-
Review of Systems:
General appearance: fever (-), anorexia (-), body weight loss (-)
Head and Neck: headache (-), sorethroat (-), rhinorrhea (-), blurred vision (-)
Chest: chest pain (-), dyspnea (-), cough (-) hemoptysis (-), sputum (-)
Abdomen: vomiting (-), diarrhea (-), flank pain (-), constipation (-), stool incontience (-)
GU/GYN: dysuria (-), hematuria (-), nocturia (-), urinary incontience (-)
Physical Examinations:
General Appearance:
Cons: clear, JOMAC: fair
ill-looking, not dehydration, not anemia
Head and Neck:
supple, LAP (-), JVE (-), no soreness, no tenderness
Chest:
symmetric expansion, no tenderness, no subcutaneous emphysema,
breathing sound: clear, no rale, no wheezing
Heart:
regular heart beat
Abdomen:
soft, flat, no tenderness, no muscle guarding,
no rebounding pain, no palpable mass,
bowel sound: normoactive
Genitalia:
no suprapubic tenderness, no gross hematuria,
no dysuria, no urinary retension or incontinence
Orthopedic Physical Examination:
Wound:old op scar,right hip
Pain: lower back pain radiation to left leg
Range of Motion:limited of motion due to pain of spine.
Function:
motor:intact
sensory: intact
Deformity: Nil
Neurovascular: intact
Neurological examination and specific finding
1 pain and numbness distribution
dermatone
lower bck pain >or < lower leg radiation pain
2 muscle power
quadriceps r,t l.t
EHL r,t l,t
FHL r,t l.t
3 reflexs
knee r,t l.t
ankle r,t l,t
4 anal tone and spincter function
5 SLRT r,t l,t
6 Other :
Knocking pain
local tenderness
operation scar or skin markings
trunk deformity
muscle wasting or spasm
lower back pain radiation to left leg with numbness few,left leg
weakness,bilateral big toe dorsiflexion function poor,and SLRT test showed
(R -/L -)
Laboratory Data:
L-spine MRI:
1.Degenerative change of L-spine with spurs formation and desiccation of lumbar discs.
2.L2-3:Grade 1 retrolisthesis.
3.L3-4:Posterior herniate disc and hypertrophied bil. ligamentum flavum, causing moderate spinal stenosis.
4.L4-5:Marked disc space narrowing and Rt posterolateral herniated disc, causing compression to the Rt lateral recess.
5.L5-S1:Facet joint spurs formation, causing Rt neural foramen.
Impression:
Spine stenosis.
Plans:
1.Arrange operation--Laminectom+Disectomy on
2.Consult CV for evaluation heart function for op risk.
五.【Tibia plateau fracture】
Chief Complaint: painful swelling of the left knee due to motor vehicle accident this morning
Present illness:
The 67 y/o man had a motor vehicle accident (汽車從右邊撞上倒地) this morning. He complained of painful disability and swelling of the left knee. He denied loss of consciousness, nausea, vomiting, chest pain, abdominal pain, or other associated injury.
He was sent to our ER for evaluation. At ER, the patients presented with left knee pain, swelling with hemoarthrosis, tenderness, limited ROM, distal sensory and motor intact. Radiographs showed a left lateral tibia plateau fracture with hemoarthrosis. So he was admitted for further evaluation and management.
Past history:
1.H/T(-)
2.DM(-)
3.Heart disease (-)
4.Present medication
5.Operation history
Family history:
H/T(-), DM(-), Heart disease (-), cancer (-)
Review of the system:
General appearance: fever (-), anorexia (-), body weight loss (-)
Head and Neck: headache (-), sorethroat (-), rhinorrhea (-)
Chest: chest pain (-), dyspnea (-), cough (-)
hemoptysis (-), sputum (-)
Abdomen: vomiting (-), diarrhea (-), flank pain (-),
constipation (-), stool incontience (-)
GU: dysuria (-), hematuria (-), nocturia (-),
urinary incontience (-)
Physical examination :
Vital sign--
General Appearance:
Cons: clear, JOMAC: normal
not ill-looking, not dehydration, not anemic
Head and Neck:
supple, LAP (-), JVE (-), no soreness, no tenderness
Chest:
symmetric expansion, no tenderness, no subcutaneous emphysema,
breathing sound: clear, no rale, no wheezing
Heart:
regular heart beat
Abdomen:
soft, flat, no tenderness, no muscle guarding,
no rebounding pain, no palpable mass,
bowel sound: normoactive
Genitalia:
no suprapubic tenderness, no gross hematuria,
no dysuria, no urinary retension or incontinence
Orthopedic Physical Examination:
Wound: abration wound over left nee area
Pain: left knee
Range of Motion: left knee painful limitation
Function:
motor: intact
sensory: intact
Deformity: left knee
Neurovascular: intact
Specific Finding: left knee pain and swelling with suprapatellar area hemoarthrosis
and abration wound, left knee stability can't evaluate due to severe pain
Laboratory exam:
Radiogram: left lateral tibia plateau split depression fracture with hemoarthrosis
Biochemistry data--
CBC/DC:
WBC: 10x3/uL, Hb: g/dL, PLT: 10x3/uL, PT: sec, APTT: sec
Biochemistry and electrolyte:
BUN: mg/dL, cr: mg/dL, GPT: IU/L
Na: meq/L, K: meq/L, Glucose: mg/dL
Diagnosis:
Left lateral tibia plateau split depression fracture, Schatzker type II
Differential diagnosis:
Plan to treatment:
1.ORIF with buttress plate
2.Prophylactic antibiotic use and analgesic treatment
3.On long leg cast protection for 1 month
4.Ambulation with walker aid with partial weight bearing of the injury limb for 3 months
5.Rehabilitation exercise
六.【TKR】
Chief Complaint: painful motion and disability of the left knee for years that has been aggravating recently.
Present Illness:
This 65-year-old female patient complained of painful motion of bilateral knees for years. The pain is much worse when the patient is doing sporting activities and is aggravated when she is trying to go up/down stairs.
The patient could walk <50 meters without pain. She gets up from sitting position with great difficulty. Squat is very difficult for the patient.
The patient cameto our OPD 4 years ago. At that time, physical and X-ray exams had led to the impression of bilateral knee joint osteoarthritis, plica syndrome, and meniscal tear. He underwent a bilateral arthroscopic examination and debridement on 10/24/2006. After the discharge, she was kept on regular OPD follow up. In recent one year, the left knee pain became worse. Therefore, she was admitted for surgical intervention.
Past History:
1.H/T(-)
2.DM(-)
3.Heart disease (-)
4.OP history(-)
900312,900625 Rt. chronic paranasal sinusitis
10/24/2006 Both Knee Plica Syndrome, Both Meniscus Tear, Osteoarthritis → Arthroscopic Examination, Partial Meniscectomy, Plica resection, Debridement
Personal History:
Allergy (-), Tobacco (-), Alcohol (-)
Drugs (-)
Family History:
H/T(-), DM(-), Heart disease (-)
Review of Systems:
General appearance: fever (-), anorexia (-), body weight loss (-)
Head and Neck: headache (-), sore throat (-), rhinorrhea (-)
Chest: chest pain (-), dyspnea (-), cough (-)
hemoptysis (-), sputum (-)
Abdomen: vomiting (-), diarrhea (-), flank pain (-),
constipation (-), stool incontience (-)
GU/GYN: dysuria (-), hematuria (-), nocturia (-),
urinary incontience (-)
menopause (+)
Physical Examinations:
General Appearance:
Cons: clear, JOMAC: normal
ill-looking, not dehydration, not anemic
Head and Neck:
supple, LAP (-), JVE (-), no soreness, no tenderness
Chest:
symmetric expansion, no tenderness, no subcutaneous emphysema,
breathing sound: clear, no rale, no wheezing
Heart:
regular heart beat
Abdomen:
soft, flat, no tenderness, no muscle guarding,
no rebounding pain, no palpable mass,
bowel sound: normoactive
Genitalia:
no suprapubic tenderness, no gross hematuria,
no dysuria, no urinary retension or incontinence
Orthopedic Physical Examination:
Wound: bilateral knees op scars
Pain: both knees tenderness, painful motion
Range of Motion:left knee painful limited ROM:10-100
Function:
motor:intact
sensory: intact
Deformity: both knees varus deformity
Neurovascular: intact
knee score:42
Laboratory Data:
W.B.C.[7.9 10^3/uL]，Hb[13.3 g/dL]，Platelet count[172 10^3/uL]，P.T.[9.6 Sec]，A.P.T.T.[26.6 Sec]
BUN[15 mg/dL]，Glucose (Random)[116 mg/dL]，Creatinine[0.82 mg/dL]
Na[139.6 mEq/L]，K[3.98 mEq/L]，S-GOT(AST)[21 IU/L]，S-GPT(ALT)[12 IU/L]
x-ray: Osteoarthrosis with medial space loss, osteophyte, genu varum.
Impression:
Both knees Osteoarthritis
Plans:
OP: TKR, left
Pre-op evalaution
Arrange rehabilitation program
七.【Wrist fracture】
Chief Complaint: Left wrist pain post traffic accident (or fall) for XXX days.
Present illness:
This 18 year-old male (or female) patienthas suffered from left wrist pain and swelling due to traffic accident (騎機車跌倒) (or fall during walking / fall from heightabout XXXX meters) for 4 days. He visited our LMD for help (or was sent to our ER). Painful disability of left wrist and volar (or dorsal) deformity were noted. The radiograph showed a left Colles fracture, Smith fracture, and Barton's fracture. We suggested operation and discussed surgical risks with the patient and family. They agreed to take the risks, and he was then transferred to our ortho ward for surgical intervention.
Past history:
1.H/T(-)
2.DM(-)
3.Heart disease (-)
4.present medication
5.operation history
Family history:
H/T(-), DM(-), Heart disease (-)
Review of the system:
General appearance: fever (-), anorexia (-), body weight loss (-)
Head and Neck: headache (-), sorethroat (-), rhinorrhea (-)
Chest: chest pain (-), dyspnea (-), cough (-)
hemoptysis (-), sputum (-)
Abdomen: vomiting (-), diarrhea (-), flank pain (-),
constipation (-), stool incontience (-)
GU: dysuria (-), hematuria (-), nocturia (-),
urinary incontience (-)
Physical examination :
Vital sign--
General Appearance:
Cons: clear, JOMAC: normal
ill-looking, not dehydration, not anemic
Head and Neck:
supple, LAP (-), JVE (-), no soreness, no tenderness
Chest:
symmetric expansion, no tenderness, no subcutaneous emphysema,
breathing sound: clear, no rale, no wheezing
Heart:
regular heart beat
Abdomen:
soft, flat, no tenderness, no muscle guarding,
no rebounding pain, no palpable mass,
bowel sound: normoactive
Genitalia:
no suprapubic tenderness, no gross hematuria,
no dysuria, no urinary retension or incontinence
Orthopedic Physical Examination:
Wound: right ankle abrasion wound
Pain: left wrist
Range of Motion: left wrist painful limitation
Function:
motor: intact
sensory: intact
Deformity: left wrist
Neurovascular: intact
Specific Finding: left wrist swelling, left arm weakness
Laboratory exam:
radiogram-- angulation ; traslation; radial shortening and volar tilt,radial inclination