Physical Exam - Orthopedic Hand Exam

[Right/Left] hand notable for [abrasion/laceration/swelling] of the [dorsal/palmar aspect of the index/middle/ring/pinky/thumb].  [Full/Limited] active range of motion of the [right/left index/middle/ring/pinky/thumb] at the [distal interphalangeal (DIP)/proximal interphalangeal (PIP)/metacarpophalangeal (MCP) joint] [motion limited to ##°].  [Full/Limited] passive range of motion of the [right/left index/middle/ring/pinky/thumb] at the [distal interphalangeal (DIP)/proximal interphalangeal (PIP)/metacarpophalangeal (MCP) joint] [motion limited to ##°]. 

[Normal/Abnormal] Allen's test (normal reperfusion from the ulnar artery after temporary occlusion of the radial and ulnar arteries, suggesting good collateral flow) of the [right/left] hand. 

[Remainder of extremity exam unremarkable.]

Discharge Instructions - Groin Strain

As discussed in the Emergency Department prior to discharge, you have been diagnosed with a groin strain.  A groin strain happens when one of the muscles in the inner thigh gets stretched too much or too quickly, or works too hard.  This sometimes makes the muscle tear.  This is sometimes also called a “pulled groin.”

A groin strain can happen while exercising, such as from suddenly changing direction or during an accident.  The muscles involved in a groin strain are called the adductor muscles, which connect the groin muscles to the thigh and pull the legs toward each other.

A groin strain is the most common cause of groin pain, especially in active adults.  It can be mild or severe.  Treatment involves resting the muscles of the groin and avoiding activities that cause pain.  You can ice the area for about 10 minutes, and then remove the ice for several minutes to prevent frostbite.  You can take Acetaminophen (also known as Tylenol) or Ibuprofen (also known as Advil or Motrin) for the pain.

Return to the Emergency Department for worsening pain, testicular pain or mass, fever (≥38.0 °C or 100.4 °F), or any new or concerning symptoms.

MDM - Ligamentous Knee Injury

[##]-year-old [male/female] with [right/left] knee pain [and injury] with history and exam consistent with likely [medial/lateral anterior/posterior collateral/cruciate] ligament injury.

Initial consideration in this patient included ligamentous injury to the medial collateral ligament (MCL), lateral collateral ligament (LCL), anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), and medial and lateral meniscus, knee dislocation, patellar and other knee fractures, patellar and quadriceps tendon injury or rupture, arthritis, pes anserine and prepatellar bursitis, and septic arthritis amongst others.

Patient present with [right/left] knee pain in the setting of [describe injury] concerning for ligamentous injury to the knee.  Patient noted to have tenderness to palpation [over the medial/lateral joint line concerning for MCL injury/LCL injury] on exam.  Specialized testing performed on the [right/left] knee as noted above with [positive valgus (abduction) stress test suggestive of MCL injury/positive varus (adduction) stress test suggestive of LCL injury/positive anterior drawer test/Lachman’s test suggestive of ACL injury/positive posterior drawer test suggestive of PCL injury].  Imaging of the [right/left] knee [felt to not be indicated in a patient meeting all Ottawa Knee Rules/with no evidence suggestive of bony injury on exam/obtained with plain films noted to be unremarkable/ findings].  The patient was noted to have no evidence of associated [collateral/cruciate ligament/any other] injuries.  Patient provided with [compression sleeve/knee immobilizer/crutches] in the ED prior to discharge [and noted to have improved pain after treatment with Toradol/etc.].

Prior to discharge, we discussed return precautions, symptomatic treatment with rest, ice, compression, and exercises as described in the handout provided at time of discharge, and follow up with primary care doctor within one week for further evaluation, and the patient demonstrated understanding and agreement with this plan.  We specifically discussed that while additional imaging, including MRI, may ultimately be a part of the management of this condition, it is not part of the emergent management of this condition.  We recommended close follow up with their primary care provider for further discussion of additional imaging, and the patient demonstrated understanding and agreement.

https://orthoinfo.org/en/diseases--conditions/common-knee-injuries/

https://orthoinfo.org/en/diseases--conditions/collateral-ligament-injuries/

https://orthoinfo.org/en/diseases--conditions/combined-knee-ligament-injuries/

https://orthoinfo.org/en/recovery/knee-conditioning-program/knee-pdf/

https://orthoinfo.org/en/staying-healthy/knee-exercises/

MDM - Medial Epicondylitis

[##]-year-old [male/female] with [right/left] elbow pain [and swelling] with history and exam consistent with medial epicondylitis (“golfer’s elbow”).

Initial consideration in this patient included medial epicondylitis, distal humeral, radial head, olecranon and other elbow fractures, lateral epicondylitis, biceps tendon rupture, and septic bursitis among others.

Patient presented with [right/left] elbow pain with tenderness to palpation noted over the medial epicondyle on exam.  Patient noted to have [golf/pitching/rock climbing/describe activity] predisposing to overuse syndrome.  Patient noted to have reproduction of pain with forced flexion and pronation of the [right/left] forearm and wrist.  Neurovascular exam of the distal [right/left] upper extremity [noted to be unremarkable/notable for findings].  Plain films were [felt to not be indicated in patient without significant preceding trauma/bony tenderness/obtained and noted to be unremarkable].

Prior to discharge, we discussed return precautions, specifically for development of weakness or numbness (especially ulnar neuropathy), symptomatic treatment with rest, ice, NSAIDs, and compression, stretching exercises (provided patient with handout from American Academy of Orthopaedic Surgeons (AAOS)), and follow up with primary care provider for further evaluation and consideration of referral to physical therapy, and the patient demonstrated understanding and agreement with this plan.

https://orthoinfo.org/en/recovery/epicondylitis-therapeutic-exercise-program/

https://orthoinfo.org/en/diseases--conditions/elbow-injuries-in-the-throwing-athlete/

MDM - Lateral Epicondylitis

[##]-year-old [male/female] with [right/left] elbow pain [and swelling] with history and exam consistent with lateral epicondylitis (“tennis elbow”).

Initial consideration in this patient included lateral epicondylitis, distal humeral, radial head, olecranon and other elbow fractures, medial epicondylitis, biceps tendon rupture, and septic bursitis among others.

Patient presented with [right/left] elbow pain with tenderness to palpation noted over the lateral epicondyle on exam.  Patient noted to have [tennis/describe activity] predisposing to overuse syndrome.  Patient noted to have reproduction of pain with forced extension and supination of the [right/left] forearm.  Neurovascular exam of the distal [right/left] upper extremity [noted to be unremarkable/notable for findings].  Plain films were [felt to not be indicated in patient without significant preceding trauma/bony tenderness/obtained and noted to be unremarkable].

Prior to discharge, we discussed return precautions, specifically for development of weakness or numbness (especially ulnar neuropathy), symptomatic treatment with rest, ice, NSAIDs, and compression, stretching exercises (provided patient with handout from American Academy of Orthopaedic Surgeons (AAOS)), and follow up with primary care provider for further evaluation and consideration of referral to physical therapy, and the patient demonstrated understanding and agreement with this plan.

https://orthoinfo.org/en/diseases--conditions/tennis-elbow-lateral-epicondylitis/

https://orthoinfo.org/en/recovery/epicondylitis-therapeutic-exercise-program/

Physical Exam - Orthopedic Ankle Exam

[No/Minimal/Moderate] tenderness to palpation along the posterior edge of the distal 6 cm of the [right/left] fibula.  [No/Minimal/Moderate] tenderness to palpation along the posterior edge of the distal 6 cm of the [right/left] tibia.  [No/Minimal/Moderate] swelling to the [medial/lateral] [right/left] ankle [with/without] palpable bony deformity.  [No/Minimal/Moderate] ecchymosis to the [medial/lateral ankle/sole of the foot]. 

[Negative/Positive] anterior drawer test of the [right/left ankle].  [Negative/Positive] inversion (supination) test of the [right/left ankle].  [Negative/Positive] eversion (pronation) test of the [right/left ankle].

[Remainder of extremity exam unremarkable.]

https://www.orthobullets.com/foot-and-ankle/7005/ankle-ligaments