Date: [DATE]
Patient: [Patient Name]
MRN: [Medical Record Number]
Subjective:
Pain level (numeric rating scale) in the wrist and forearm.
Any functional limitations related to the fracture (e.g., difficulty with activities of daily living).
Inquire about pain medication use, dosage, and effectiveness.
Ask about any sensory changes (numbness, tingling) in the hand or fingers.
Objective:
Vital Signs: Include heart rate, blood pressure.
Temperature may be relevant if there is a concern for infection.
Physical Exam:
Inspection: Look for swelling, bruising, deformity of the wrist.
Palpation: Assess for tenderness at the fracture site and along the radius and ulna.
Evaluate wrist motion (flexion, extension, supination, pronation) and pain with movement.
Neurovascular exam: Check for sensation in the hand and fingers, capillary refill time, and pulse quality in the radial and ulnar arteries.
Imaging:
Mention the type of fracture based on recent X-rays (e.g., displaced, non-displaced, comminuted).
Assessment:
Distal radius fracture (dominant/non-dominant hand).
Specify the fracture type based on X-ray findings.
Alignment: Indicate if the fracture is acceptable reduction or malaligned.
Stability: Describe if the fracture is stable or unstable.
Range of motion (ROM) limitations: Mention any limitations in wrist movement.
Neurovascular status: Document any sensory or vascular concerns.
Plan:
Treatment plan based on fracture type and displacement:
Non-operative management:
Cast immobilization: Specify the type of cast (e.g., short arm cast, bivalar cast) and duration of wear.
Pain management: Medications and dosage (e.g., NSAIDs, opioids).
Physical therapy referral for ROM exercises after cast removal.
Operative management: If surgery is planned, briefly mention the surgical approach and anticipated timeline for recovery.
Follow-up:
Schedule the next clinic visit for cast recheck or suture removal (if applicable).
Indicate when to initiate physical therapy.
Advise on pain management and wrist elevation at home.
Education:
Explain activity restrictions related to the cast.
Instruct on cast care (keeping it dry, signs of complications to watch for).
Discuss expected recovery time and functional limitations.
Note: This is a template and should be adapted to the specific patient encounter. Document important details regarding fracture characteristics, treatment approach, and follow-up plan.