Chapter 4: The Musculoskeletal System | Emma Almondo's Chart Note

CHART NOTE

Patient Name: Almondo, Emma
ID Number: 14288
Examination Date: January 8, 20xx

SUBJECTIVE
Emma was babysitting her neighbor's 7-year-old son when he threw his spaghetti onto the floor. As she was cleaning the spaghetti off the floor, Emma slipped and fell to the floor, injuring her left wrist and left knee.

OBJECTIVE
The left wrist is swollen with obvious deformity. There is normal sensation of the fingers with normal motion of the fingers. Patient has pain with movement of the wrist. Left patella is tender to palpation (examination with the hands). There is joint effusion of the knee. Sensation and movement distal to the knee are both normal. X-rays of the left wrist reveal a fracture of the distal radius with approximately a 20-degree dorsal angulation, which is displaced about 30 percent from its normal position. There is no ulna (inner medial bone of the forearm) fracture. X-rays of the left patella shows a fracture with no displacement of the fragments.

ASSESSMENT

  1. Fracture, left wrist
  2. Patellar fracture, left knee

PLAN
Knee immobilizer was placed. Patient was instructed in crutch walking. She should bear as little weight as possible on the left knee. Posterior splint with elastic bandage was placed on the forearm. Patient was given acetaminophen with codeine for pain. An appointment with Orthopedic Specialists was made for Wednesday. Possible open reduction internal fixation (surgical realignment of bones with implants to guide the healing process).


G-W Learning