Date:
Patient: [Patient Name], [MRN]
Attending Physician: [Physician Name]
Reason for Visit: Follow-up for clavicle fracture, evaluation of pain, X-ray findings (if recent), and functional progress.
SOAP
Subjective (S):
History of Present Illness:
Inquire about the following details of the injury:
Mechanism of injury (fall, direct blow)
Time since injury
Pain level (location, character, severity)
Use of pain medication and its effectiveness
Functional limitations (difficulty with daily activities due to pain or sling immobilization)
Past Medical History:
Briefly summarize relevant past medical history, including:
Significant medical conditions (e.g., osteoporosis) that can affect healing
Previous fractures
Social History:
Inquire about occupation and potential impact of limitations on work activities.
Objective (O):
Vital Signs:
Record temperature, heart rate, blood pressure, and respiratory rate.
Physical Exam:
Assess for:
Deformity or swelling at the clavicle fracture site
Point tenderness at the fracture site
Active and passive range of motion of the shoulder (may be limited due to pain or sling)
Neurovascular examination of the arm (assessing sensation and circulation in the hand and arm)
Imaging (if recent X-rays available):
Briefly describe X-ray findings, including fracture location, displacement of bone fragments, and angulation (degree of angulation may influence treatment decisions).
Assessment (A):
Fracture Type:
Describe the type of clavicle fracture based on location (midshaft, medial, lateral) and displacement (displaced or non-displaced).
Treatment Plan Adherence:
Assess if the patient is adhering to the prescribed treatment plan (sling immobilization, medications, physical therapy).
Pain Control:
Evaluate the effectiveness of pain management strategies.
Functional Progress:
Assess the patient’s progress in regaining shoulder mobility and ability to perform daily activities.
Plan (P):
Pain Management:
Adjust pain medication regimen as needed to ensure adequate pain control.
Immobilization:
Re-evaluate the need for sling immobilization based on fracture healing and pain level. Consider transitioning to a less restrictive sling or brace as appropriate.
Physical Therapy (if indicated):
Initiate or continue physical therapy to improve shoulder range of motion, strength, and function.
Follow-up Imaging:
Schedule follow-up X-rays at appropriate intervals to monitor fracture healing.
Return to Activity:
Gradually progress weight-bearing activities on the affected arm as tolerated and with guidance from physical therapy.
Referral (if indicated):
Consider referral to an orthopedic surgeon for patients with:
Complex fracture patterns requiring surgery
Inadequate pain control despite conservative measures
Slow healing or complications
Patient Education:
Educate the patient about clavicle fractures, healing process, and importance of adhering to the treatment plan.
Provide information on proper sling wear and care (if applicable).
Discuss pain management strategies and potential side effects of medications.
Explain the importance of physical therapy exercises and adherence to the rehabilitation program.
Provide guidance on gradually resuming activities as tolerated.
Offer resources for educational materials on clavicle fracture recovery.