Comprehensive New Patient - PS Template

Thank you for the referral of Mr. John Smith, seen today, 1 November 2024, in consultation.
Reason for Visit: Mr. Smith presented with concerns about a persistent deformity and pain in his right hand following a previous injury.
History of present illness: Mr. Smith has been experiencing significant pain and stiffness in his right hand for the past six months, following a fall that resulted in a fracture. Despite initial treatment with physiotherapy and pain management medications, his symptoms have not improved. He reports difficulty in performing daily tasks and wishes to explore surgical options to restore function and alleviate pain.
Medical/Surgical History:
- Previous right hand fracture
- Hypertension
Medications:
- Lisinopril 10 mg daily
- Ibuprofen 400 mg as needed for pain
Allergies:
- No known drug allergies
Social/Occupational History and Functional Inquiry:
- Works as a carpenter, which requires fine motor skills
- Non-smoker, occasional alcohol use
Physical Examination:
- Vitals: Blood pressure 130/85 mmHg, heart rate 72 bpm
- Musculoskeletal examination: Swelling and tenderness in the right hand, limited range of motion, decreased grip strength
- Neurovascular examination: Intact nerve function and adequate blood supply
Investigations:
- X-ray of the right hand shows malunion of the fracture
Assessment & Plan:
1. Right hand deformity and pain
- Differential diagnosis includes post-traumatic arthritis
- Plan for surgical intervention to correct the malunion, with cementless fixation and outpatient procedure
- Routine postoperative medications planned
- Post-operative care will include physiotherapy and pain management
- Referral to physiotherapy for pre-operative strengthening exercises
Additional Notes:
- Patient educated on the surgical procedure, potential complications, and the importance of rehabilitation
- Informed consent was obtained after a discussion of the nature of the treatment proposed, the nature of the condition, the treatment alternatives, the expected postoperative course, and material risks which include but are not limited to infection, bleeding, scarring, seroma, hematoma, pain, swelling, wound complications and wound healing including potential tissue necrosis, nerve damage, asymmetry, the possibility of an unfavorable cosmetic result, and, where applicable, general anesthesia risks such as DVT/PE, MI, or stroke. The patient gave informed consent for the discussed procedure.
- Sensitive patient exams are always conducted in the presence of a chaperone.