Chapter 4: The Musculoskeletal System | Amos Stoudt's Chart Note

CHART NOTE

Patient Name: Stoudt, Amos
ID Number: 12114
Examination Date: May 19, 20xx

SUBJECTIVE
This 23-year-old male presents with lower right arm pain. Two days ago he was helping his father cut up tree branches from last week's violent storm when he was struck by a falling limb. When he uses his right hand, he has swelling and pain with pronation (turning of the hand and forearm so the palm faces downward), supination (turning of the hand and forearm so the palm faces upward), and gripping.

OBJECTIVE
He has mild edema over the distal radius (outer lateral bone of the forearm), approximately 8 cm proximal to the radial styloid process (small protrusion of bone). Neurovascularly intact. He has full range of motion of his hand and phalanges. X-rays confirm a nondisplaced fracture of the distal forearm.

ASSESSMENT
Right radial shaft fracture in good alignment.

PLAN
Fiberglass cast applied. Patient provided with arm sling and told to keep the arm elevated. Advised use of Advil®, aspirin, or Tylenol® for pain. Follow follow-up appointment in 10 days.