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 swelling in 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 bone setters 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 fat
suppression ), coronal ( PD & PD fat suppression ) and axial ( PD fat
suppression ) 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 shoulder is
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 pain radiating 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 weakenss of 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 came to 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) patient has suffered from left wrist pain and
swelling due to traffic accident (騎機車跌倒) (or fall during walking / fall
from height about 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
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 Colles fracture , Smith fracture, Barton's fracture
Differential diagnosis:
Plan to treatment:
1.ORIF with K-pins , buttress plate ; ESF
2.on long arm cast
八.【Femoral Neck】
主訴
Painful disability of the right hip after falling down this morning

現病史
[Informant:本人]
This 72 year-old male patient has a history of Hypertension for more than
10 years without regular medical control. He denied history of cardiovascular
accident and coronary artery disease.
He kicked something in the bathroom and then fell down at 4:30AM this
morning without consciousness loss. His right hip collided to the ground and he
presented with painful disability of the right hip since falling down.
He was then sent to our emergent department by emergency medical
technician system this afternoon. At emergent department, physical exam showed
right hip pain and tenderness. The neurovascular function of the right lower
limbs was intact with adequate muscle power 3~4. X-ray was performed and showed
right femoral neck fracture. Due to above findings, he was admitted for further
surgical intervention.

過去病史
1.Hypertension(+) without regular medical control
2.Diabetes mellitus(-)
3.Cardiovascular accident (-)
4.Coronary artery disease (-)

個人病史
Allergy (-)
Tobacco (+) 1 ppd for more than 20 years
Alcohol (-)
Drugs (-)
Occuptional history：Nil
Contact history：Nil
Travel history：Nil
Betnut history：Nil

過敏史:
食物(無已知過敏史)
非食物(無已知過敏史)
 藥物 (無已知過敏史)

家族病史
1.Hypertension(+) without regular medical control
2.Diabetes mellitus(-)
3.Cardiovascular accident (-)
4.Coronary artery disease (-)
5.Cancer (-)

系統回顧
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 (-)

身體檢查
Vital signs: T=37 ℃ P=80 /min R=18 /min BP=148/85 mmHg
General Appearance:
Cons: clear E4V5M6, 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:nil
Pain:right hip pain
Range of Motion:limited due to Rt hip pain
Function:impaired, can not stand
motor:dorsiflexion and plantar flexion: intact
sensory: intact
Deformity:right leg shortening
Neurovascular:
Rt ankle and toes movement intact.
Rt dorsalis pedis (++)
Rt posterior tibialis (++)

檢查摘要(實驗室及理學檢查)
Pelvic X-ray
Fracture of right femoral neck.
099-12-02，W.B.C.[14.7 10^3/uL]，R.B.C.[4.87 10^6/uL]，Hb[16.7 g/dL]，Hct[48.0
%]，Platelet count[242 10^3/uL]，Segment[83.9 %]
099-12-02，P.T.[9.8 Sec]，A.P.T.T.[26.7 Sec]
099-12-02，Glucose (Random)[304 mg/dL]，Na[136.8 mEq/L]，K[3.66 mEq/L]，BUN[15
mg/dL]，Creatinine[1.20 mg/dL]，S-GOT(AST)[28 IU/L]，S-GPT(ALT)[28 IU/L]

住院主要臆斷
Right femoral neck fracture. Garden type IV. Transcervicle type.

其它相關診斷
Hypertension poor control

住院診療計劃
1.Arrange surgical interveniton
(Open reduction with cannulated screws fixat ion)
2.Pain contorl
3.Inform operation and anesthesia risk to patient and his family
4.Education encouraging post operation sitting up and prevent sliding down
5.Rehalbilitation program: Wheelchair or walker ambulation with
right lower limb non-weight bearing 3 months
九.【Femoral shaft】
主訴
Left thigh painful disability after traffic accident 4 hours ago

現病史
[Informant:本人]
This 34 year-old male patient has left thigh painful disability after
traffic accident 4 hours ago. He was riding motorcycle with his helmet on when
he was hit by another motorcycle moving with relative velocity about 50
kilometers per hour while he was crossing the road. He was first sent to Chiali
hospital by emergency medical technician system. He had abrasion wounds on the
left thigh without laceration wound. His Left femoral x-ray showed a left
femoral shaft fracture.
Then under the request of the patient's family, he was referred to our
hospital for further surgical intervention.
At our emergency department, his physical examination showed local
tenderness, swelling, and deformity in the left thigh. Active range of motion of
his left hip and knee joint was limited; sensation of the left lower limb was
intact. Motor function of his left ankle was intact with dorsalis pedia artery
pulsation (++) and posterior tibialis artery pulsation (++). His left big toe
has pain on passive stretch (-). So he was admitted for further management.

過去病史
1.Hypertension(-)
2.Diabetes mellitus(-)
3.Trauma history (+):
Lt distal radius fracture after long arm casting at clinic
5 years ago with well union
4.Coronary artery disease (-)
5.Cerebral vascular accident (-)

個人病史
Allergy (-)
Tobacco (-)
Alcohol (-)
Drugs (-)
Occuptional history：heavy worker
Contact history：無
 Travel history：無
Betnut history：無

過敏史:
食物(無已知過敏史)
非食物(無已知過敏史)

家族病史
1.Hypertension(-)
2.Diabetes mellitus(-)
3.Coronary artery disease (-)
4.Cerebral vascular accident (-)
5.Cancer(-)
系統回顧
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 (-)

身體檢查
Vital signs: T=36.6 ℃ P=92 /min R=19 /min BP=152/74 mmHg
General Appearance:
Cons: clear, JOMAC: normal
ill-looking, not dehydration, not anemic
Head and Neck:
supple, LAP (-), JVE (-), no soreness, no tenderness
conjuntiva paleness(-)
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: nil
Pain: Left thigh(+). Left hip (-)
Range of Motion: limited due to left femoral shaft fracture
Function:
motor: left leg MP:3
sensory: intact
Deformity: left thigh external rotation
Neurovascular:
Left dorsalis pedia artery pulsation (++)
Left posterior tibialis artery pulsation (++)
Left big toe passive stretch pain (-)

檢查摘要(實驗室及理學檢查)
099-12-10，W.B.C.[10.2 10^3/uL]，R.B.C.[3.20 10^6/uL]，Hb[11.2 g/dL]，Hct[32.6
%]，Platelet count[156 10^3/uL]

099-12-10，Glucose (Random)[136 mg/dL]，Na[137.2 mEq/L]，K[4.91 mEq/L]，BUN[28

mg/dL]，Creatinine[2.00 mg/dL]，S-GOT(AST)[40 IU/L]，S-GPT(ALT)[23 IU/L]

099-12-10，CRP[1.6 mg/L]，Troponin I[0.00 ng/mL]，CK-Total[501 IU/L]，CK-MB

mass[6.6 ng/mL]

住院主要臆斷
Left femoral shaft fracture, provimal third, long spiral shape

其它相關診斷
Nil

住院診療計劃
1.Pain control with intravenous fluid resuscitation
2.Prepare pack RBC for potential blood transfusion
3.Arrange left femoral sahft open reduction and fixation
with interlocking nail
4.Inform operation and anesthesia risk:
a.pulmonary embolism and anemia due to blood loss
b.other vital organ trauma possibility and observation at ward
5.Inform preoperation undetectable left femoral neck fracture about 5%
6.Post operation rehalbilitation program:
Lt knee and left hip active range of motion
7.Post operation ambulation training protocol:
Crutches aid ambulation with left lower limb partial weight bearing
Prevention sliding down education